Mehmet KABALCI, Nesimi GÜNAL, Ali BOLAT, Koray DURAL, Berkant ÖZPOLAT

Sternotomi fiksasyon metodlarının karşılaştırılması: Sert-rijit fiksasyona karşı aşırı kuvvet karşısında esnekliği ayarlanabilen yarı-esnek fiksasyon: Deneysel biyomekanik çalışma

Amaç: Monofilament paslanmaz çelik tel (TEL), multifilaman paslanmaz çelik halat (HALAT), polipropilen bant kelepçe (KELEPÇE) ve multifilaman elastan fiber (ELASTAN) sütürler, deneysel düzenekle in vitro olarak kemik hasarı, elastik modül, çekme dayanımı, uzama ve kopma parametreleriyle karşılaştırılmıştır.Gereç ve Yöntem: Koyun göğüs kafesleri median sternotomiyle iki parçaya ayrıldı ve sonrasında ilgili kapama yöntemiyle bir araya getirildi. Bu haliyle deneysel düzeneğe sabitlenerek 100-800N çekme testine (Instron, USA) tabi tutuldu. İlk aşamada sütür parçaları teker teker, sonra halka yapılıp düğümlenerek ve son aşamada sütüre edilmiş koyun göğüs kafesi şekinde test edildi. Sternumun maksimum kuvvetteki ayrışma mesafesi, sütürün kopma ve uzaması, elastik-plastik faz seviyeleri ve akma noktaları her aşamada kaydedildi.Bulgular:Sütür-kemik temas yüzeyi KELEPÇE’de (3.5 mm: en yüksek), ELASTAN’da (2 mm), HALAT’ta (1.1 mm), TEL’de (0.8 mm: en düşük) iken, kemik doku hasarı ELASTAN’da hiç olmadı, HALAT’ta %11, TEL’de %29 seviyesinde oldu, KELEPÇE grubunda ise kemik hasarı oluşacak kuvvete erişmeden kopma gözlendi. Sütürde uzamanın başladığı ortalama seviyeler ise TEL’de 210N (en dayanıksız), KELEPÇE’de 320N, HALAT’ta (800N: en dayanıklı) ve ELASTAN’da (800N: en dayanıklı) şeklinde izlendi.800N’luk anlık aşırı kuvvet oluşmasının simüleedildiğiya aşamada kemik veya sütür hasarı oluşmadan kemiğin bir arada kalabildiği tek yöntem ELASTAN oldu. Sonuç: Deney sonuçlarımıza göre sütür temas alanı ile kemik hasarının ters korele olduğu ve polipropilen materyal dayanımının bu alanda dayanıksız olduğu görüldü. Daha önemli olarak rijit sabitleme yerine bizim geliştirdiğimiz, 800N’a kadar rijit, daha üstünde elastik özellik gösteren ELASTAN yönteminin, anlık aşırı kuvvet altında dehissens oluşsa bile yeniden anında sternumu eski konumuna getirerek başarı sağladığı gösterildi.

Keywords:

sternotomi rijitfiksasyon, çelik kablo, çelik tel, polipropilen kelepçe, elastan,

PDF

___

1. Milton AF, cited by Kirschner M. Tratatad de tecnicaoperatoria general y especial. Barcelona: Editorial Labor, 1944;4:756–60.
2. Julian OC, Lopez-Belio M, Dye WS, Javid H, Grove WJ. Appraisal of progress in surgicaltherapy. Surgery 1957;42:753–61.
3. Orhan SN, Ozyazicioglu MH, Colak A. A biomechanical study of 4 different sternum closure techniques under different deformation modes. Interactive cardiovascular and thoracic surgery. 2017;25:750-6.
4. Aykut K, Celik B, Acıkel U. Figure-of-eight versus prophylactic sternal weave closure of median sternotomy in diabetic obese patients undergoing coronary artery bypass grafting. The Annals of thoracic surgery. 2011;92:638-41.
5. Danter MR, Saari A, Gao M, Cheung A, Lichtenstein SV, Abel JG. A New Device for Securing Sternal Wires after Median Sternotomy: Biomechanical Study and Retrospective Clinical Assessment. Innovations. 2018;13:40-6.
6. Stahle E, Tammelin A, Bergstrom R, Hambreus A, Nystrom SO, Hansson HE. Sternal wound complications--incidence, microbiology and risk factors. European journal of cardio-thoracic surgery. 1997;11:1146-53.
7. Landes G, Harris PG, Sampalis JS, Brutus JP, Cordoba C, Ciaburro H, Bernier C, Nikolis A. Outcomes in the management of sternal dehiscence by plastic surgery: a ten-year review in one university center. Annals of plastic surgery. 2007;59:659-66.
8. Tekumit H, Cenal AR, Tataroglu C, Uzun K, Akinci E. Comparison of figure-of-eight and simple wire sternal closure techniques in patients with non-microbial sternal dehiscence/Non-mikrobiyal sternal dehisens gelisen olgularda figur 8 ve basit tek tek telleme ile kapama tekniklerinin mukayesesi. The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi). 2009;9:411-7.
9. Robicsek F, Fokin A, Cook J, Bhatia D. Sternal instability after midline sternotomy. The Thoracic and cardiovascular surgeon. 2000;48:1-8.10. Balachandran S, Lee A, Denehy L, Lin KY, Royse A, Royse C, El-Ansary D. Risk factors for sternal complications after cardiac operations: a systematic review. The Annals of thoracic surgery. 2016;102:2109-17.
11. Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomy: a comprehensive review. European journal of cardio-thoracic surgery. 2002;21:831-9.
12. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. The Journal of thoracic and cardiovascular surgery. 1977;73:267-8.
13. Goldman G, Nestel R, Snir E, Vidne B. Effective technique of sternum closure in high-risk patients. Archives of Surgery. 1988;123:386-7.
14. Glennie S, Shepherd DE, Jutley RS. Strength of wired sternotomy closures: effect of number of wire twists. Interactive cardiovascular and thoracic surgery. 2003;2:3-5.
15. Cheng W, Cameron DE, Warden KE, Fonger JD, Gott VL. Biomechanical study of sternal closure techniques. The Annals of thoracic surgery. 1993;55:737-40.
16. Abbas S, Gul S, Abbas A, Iqbal M, Khan T, Khan JS. Figure-of-8 sternal closure vs simple interrupted sternal closure in reducing sternal dehiscence in patients with coronary artery bypass grafting (CABG). Pakistan Heart Journal. 2017;50.
17. Vos RJ, Jongbloed L, Sonker U, Kloppenburg GT. Titanium plate fixation versus conventional closure for sternal dehiscence after cardiac surgery. The Thoracic and cardiovascular surgeon. 2017;65:338-42.
18. Voss B, Bauernschmitt R, Brockmann G, Krane M, Will A, Lange R. Complicated sternal dehiscence: reconstruction with plates, cables, and cannulated screws. The Annals of thoracic surgery. 2009;87:1304-6.
19. Sharma R, Puri D, Panigrahi BP, Virdi IS. A modified parasternal wire technique for prevention and treatment of sternal dehiscence. The Annals of thoracic surgery. 2004;77:210-3.
20. Subramaniam T, Keita L, Veerasingam D. Sternal Talon, a novel repair for sternal dehiscence. Kardiochirurgia i torakochirurgia polska= Polish journal of cardio-thoracic surgery. 2015;12:153.
21. Bejko J, Bottio T, Tarzia V, De Franceschi M, Bianco R, Gallo M, Castoro M, Bortolussi G, Gerosa G. Nitinol flexigrip sternal closure system and standard sternal steel wiring: insight from a matched comparative analysis. Journal of Cardiovascular Medicine. 2015;16:134-8.
22. Dell’Amore A, Campisi A, Giunta D, Congiu S, Dolci G, Murana G, Suarez SM, Daddi N. Surgical options to treat massive sternal defect after failed Robicsek procedure. Journal of thoracic disease. 2018;10:410.
23. Fedak PW, Kieser TM, Maitland AM, Holland M, Kasatkin A, LeBlanc P, Kim JK, King KM. Adhesive-enhanced sternal closure to improve postoperative functional recovery: a pilot, randomized controlled trial. The Annals of thoracic surgery. 2011;92:1444-50.
24. Orhan SN, Özyazıcıoğlu MH, Çolak A. Experimental comparison of efficiency of four different sternum closure techniques. Turkish Journal of Thoracic and Cardiovascular Surgery. 2017;25;535-42.
25. Capek L, Henys P, Kalab M, Solfronk P. Failure of sternal wires depends on the number of turns and plastic deformation: combined experimental and computational approach. Interactive cardiovascular and thoracic surgery. 2018;26:777-82.
26. Marzouk M, Mohammadi S, Baillot R, Kalavrouziotis D. Rigid Primary Sternal Fixation Reduces Sternal Complications among Patients at Risk. The Annals of thoracic surgery. 2019;108;737-43.
27. Vestergaard RF, Søballe K, Hasenkam JM, Stilling M. Sternal instability measured with radiostereometric analysis. A study of method feasibility, accuracy and precision. Journal of cardiothoracic surgery. 2018;1:41.
28. Casha AR, Manché A, Gatt R, Duca E, Gauci M, Schembri-Wismayer P, Camilleri-Podesta MT, Grima JN. Mechanism of sternotomy dehiscence. Interactive cardiovascular and thoracic surgery. 2014;19:617-21.