The median sternotomy is the most common surgical
approach to the heart and therefore the most performed
osteotomy worldwide. Steel wire fixation is mostly used
for postoperative closure of the sternum (1). This tech-
nique is fast, easy to handle and economical. It has a
complication rate of less than 1% (2). This traditional
chest closing technique involves some risks, such as
possible snapping of the wires induced by coughing or
obesity, sternal fracture and ineffective healing in
patients with poor bone quality. Complications include
sternal instability and deep or superficial wound infec-
tion, with mediastinitis as most feared because of its high
mortality rate and associated increased length of stay and
hospitalisation costs (3-6).
Mediastinitis is treated by debridement and systemic
antibiotics. Wound healing can be optimized by vacuum-
assisted closure (V.A.C.®, KCI, USA), a negative pres-
sure wound therapy. After healing of mediastinitis, it is
not always obvious to obtain a stable sternal fixation.
Sternal instability alone can cause complications because
of its relatively high risk of developing a sternal infection
(7, 8). And thus, stabilisation of the sternum is the key
factor in wound healing.
Recently, a new sternal refixation system has been
available with promising results (9, 10). In this manu-
script, we evaluate our initial results with the titanium
transverse plate fixation system in four patients.
Material and methods
The Titanium Sternal Fixation System (Synthes®,
Solothurn, Switzerland) consists of two H-shaped and
two star-shaped sternum locking plates for the manubri-
um. For the sternum, straight locking plates, with a 12-
hole, 20-hole and 30-hole shape, are screwed onto the
ribs. All plates have an emergency release U-shaped pin
in the middle for quick and easy re-entry of the sternum
in cardiac emergencies, as well as re-closing by inserting
a new pin. Screws all have the same diameter (3.0 mm),
are self-tapping and have lengths of 8-10-12-14-16 and
18mm. Bending pliers enable relatively easy plate adap-
tation to the anatomy of the sternum and ribs, while drill
guides are present for precise drilling and insertion of the
screws. These guides exist in different lengths to prevent
excessively deep drilling.
The technique can be explained in 8 steps (11) :
1) Debridement and exposition of the ribs : all wires are
removed and all non vital tissue is debrided. Bilateral
pectoralis major muscle flaps are created starting
medially. Ideally, the exposition should be made until
the lateral insertion of the muscle. The overlying sub-
cutaneous tissue is to be left attached.
2) Measurement of the sternal edges : the depth gauge
measures the sternal edges next to each rib where a
plate is placed. Three millimetres should be added to
the thickness of the edge so that the plate thickness is
taken into account.
Acta Chir Belg, 2009, 109, 371-375
Titanium Transverse Plate Fixation : a New Solution for Old Sternal Problems
K. Moerenhout, I. Rodrigus, D. De Bock, W. Vergauwen, B. Stockman
Department of Cardiac Surgery, Antwerp University Hospital, Edegem, Belgium.
Key words. Titanium transverse plate fixation ; sternal wound infection ; mediastinitis ; sternal instability.
Abstract. Objective : To evaluate our initial results with the titanium transverse plate fixation system of the sternum in
Methods : Two patients with late dehiscence and persistent instability of the sternum after cardiac surgery were treated
with refixation by titanium transverse plates and screws. Two patients were treated with the same refixation method after
pre-treatment with debridement, antibiotic therapy and vacuum-assisted closure therapy for extensive mediastinitis.
Results : All four patients healed without complications. The mean postoperative length of stay was 17,3 days (range 7-
44). The instability and/or pain disappeared in all patients. The postoperative imaging showed good positioning of the
osteosynthesis material. There was no re-infection in patients with mediastinitis.
Conclusions : The titanium transverse plate fixation system is a very promising adjunct to the armamentarium of the car-
dio-thoracic surgeon for treatment of sternal problems, including dehiscence and fractures, even when mediastinitis is
involved. It offers more stability compared to simple rewiring, without the need for extensive retrosternal dissection.
3) Reduction of the sternum with superior and inferior
4) Plate selection and template contouring : selection of
a plate with adequate length is done. The plate can be
cut if necessary. The pin should be in the centre with
the closed end cranial and with a minimum of four
screws at each side of the sternum. The bending tem-
plate is cut so that the good length is obtained and is
bent in such way that it contours the sternum and ribs.
5) Orientation and contouring of the plate : the plate is
placed in such manner that it contours the ribs and
sternum and can be bent in two ways. The plate
should be placed on the superior part of the rib to
avoid intercostal vessels and nerves while drilling.
The emergency release pin should be parallel to the
midline of the sternum, with a slight angulation of
20-25° in the bending.
6) Drilling : the drill guide is inserted to ensure the lock-
ing screw to be aligned with the plate hole. While
drilling, some water is put to avoid overheating.
Some points should be taken into consideration : the
thickness of the adjacent ribs can be less than the
sternal edges. Drilling deeper than necessary is dan-
gerous considering the risk for pneumothorax.
Drilling at level of internal mammary arteries must
7) Selection and insertion of the screws : the measure-
ment of the depth of the hole is executed with the
depth gauge through the plate. The selection of the
screw is made, keeping in mind that its length does
not exceed the drilled hole, so that deeper injuries are
8) Closing : a drain is placed under the pectoral mus-
cles. Approximation of the pectoral flaps is executed
at level of the midline with individual absorbable
sutures. The subcutaneous layers and skin can then be
Prophylactic antibiotic treatment with a second genera-
tion Cephalosporine for 24 hours is indicated in clean
wounds. In refixation after mediastinitis or in case of
positive preoperative cultures, antibiotic treatment
should be prolonged according to the results of wound
culture. The drains can be removed when there is less
than 50 ml per drain per day.
The Titanium Sternal Fixation System has been used
in four patients. The first two presented cases had dehis-
cence problems, the following two had mediastinitis.
This 55-year-old man underwent an uneventful redo aor-
tic valve replacement with ascending aorta replacement
(Bentall) and mitral valve repair. The following co-mor-
bidities were observed : renal failure due to lithium ther-
apy and tabagism. The postoperative follow-up after six
K. Moerenhout et al.
weeks showed a good evolution and normal healing of
the sternotomy. However, 15 weeks after surgery, he
experienced sudden pain of the thorax and sternum. The
clinical and radiographic examination showed a loose
sternum, with two overcrossing broken sternal wires.
Because there was no real hindrance in daily life, the
decision was taken to wait and examine the patient
6 weeks later. Meanwhile, a CT-scan showed a delayed
union of the sternum at the manubrium and corpus, with
a diastasis of 12 mm (Fig. 1). The sternum refixation was
performed 5 months after initial surgery. Four plates
were placed on the corpus and one star-shaped plate was
placed on the manubrium (Fig. 2). The postoperative
radiography showed a good fixation without loosening of
the sternum (Fig. 3). Seven days later, the patient left the
hospital without any complaints. After three weeks fol-
low-up, a normal wound healing was observed.
A 73-year-old man underwent coronary artery bypass
grafting, with following construction : LIMA on the
LAD, and a vein on diagonal-, marginal- and circumflex
coronary. As cardiac risk factors we found pulmonary
embolism, hypertension, dyslipidemia, ex-tabagism and
familial antecedents. During postoperative recovery, the
patient had a superficial infection of the sternal wound
with subcutaneous emphysema. Cultures showed
Staphylococcus species and the patient was treated with
Dehiscence of the sternum on CT-scan
Titanium Transverse Plate Fixation
intravenous antibiotics (piperacilline, tazobactam) for
10 days with sufficient wound healing. Six weeks later, a
dehiscent sternum was observed on clinical examination
without complaints, although his activities were restrict-
ed until then. After a waiting time of 4 months, the com-
plaints of instability with dyspnoea persisted. Six months
after his first operation, a sternal refixation was done.
The patient was discharged after 6 days and had an
uneventful recovery. The cultures of the sternum
remained negative and the patient had no complaints of
A 42-year-old patient with a history of ethyl abuse,
tabagism, drug abuse, hepatitis B, active hepatitis C and
with a cranial trauma with cerebral haemorrhage and
psycho-organic syndrome was hospitalised for pneumo-
nia. Due to persistent dyspnoea, imaging with sonogra-
phy and a computed tomography of the thorax showed
important idiopathic pericardial effusion, for which sur-
gical pericardial fenestration was performed via lower
partial sternotomy. Two months after surgery, the patient
was re-admitted because of high fever due to a retroster-
nal abscess. Reincision and drainage of the partial ster-
notomy was performed. After extraction of the sternal
wires and extensive debridement, a VAC was applied and
antibiotics (flucloxacilline) were administrated. Despite
reasonable wound healing and negative cultures after
6 weeks of treatment, the sternum was unstable and very
painful. A sternal refixation with the Titanium Sternal
Fixation System was performed with 2 short plates and
13 screws. The postoperative evolution was uneventful
and the patient was able to leave the hospital after
11 days. After 5 weeks he had a normal wound healing
with stable sternum. Only some stiffness of the thorax
and intermittent thoracic pain were detected, for which
physiotherapy was applied.
A 67-year-old man underwent an aortic valve replace-
ment. In the medical history, COPD and arterial hyper-
tension were observed. Fourteen days after surgery, the
Positioning of the plates and screws
Chest X-Ray (Face/Profile) : sternal fixation with four plates
and star-shaped manubrium plate.
patient suffered a hemodynamic collapse with a slow
escape rhythm. Cardiac sonography showed a swinging
heart with slight compression of the right ventricle. Two
day later, the patient collapsed again and sternal instabil-
ity was observed with a suspicion of mediastinitis.
Sternal exploration showed extensive mediastinitis. After
debridement, VAC therapy was applied and antibiotics
(meropenem and flucloxacilline) were administrated.
After 15 days of VAC therapy, the sternum was fixated
with the sternum refixation system. The patient recovered
well with discharge 44 days after refixation and normal
wound healing. The main reason for postoperative stay
was of neurological aetiology after reanimation, and not
due to problems of refixation of the sternum.
All four patients recovered sternal fixation without com-
plications. The mean postoperative length of stay was
17.3 days (range 7-44). Symptoms of instability and/or
pain disappeared in all patients. The postoperative radio-
logical examinations showed plates and screws that were
in good position. No noticeable distance of the sternum
after refixation was observed. None of the patients had a
re-infection of the sternum or wound. The Titanium
Sternal Fixation System has shown excellent mid-term
results. There were no technical problems in placing the
Even though most sternums heal well at first after
cardiac surgery, there can be a non-union of the sternum
with pain, instability and pseudo-arthrosis. Even frac-
tures of the sternum can occur as a result of extensive
movements or coughing of the patient. In both complica-
tions, stabilising the sternum is necessary so re-union of
the bone can take place.
Traditionally, simple rewiring of the sternum is per-
formed. In order to put new wires, release of retrosternal
adhesions is necessary with its attending risk. With this
transverse refixation system, the surgeon stays anterior to
the sternum, without danger of damaging underlying
structures, and with good fixation in addition.
In case of mediastinitis, the classical intervention is to
remove all sternal wires combined with an extensive
debridement of the wound. Most centers rewire the
sternum when feasible. When this is impossible, the
retro-sternal space is filled with a muscle (pectoralis
major muscle) flap or an omental flap. VAC therapy is
another option that has emerged recently. The VAC-
therapy is applied until no signs of infections are
observed and cultures are negative. This technique has
shown its benefit in multiple recent studies (12-14).
Since our positive experiences with this system, the
K. Moerenhout et al.
VAC-therapy has become a standard procedure in
mediastinits. Other possible adjuncts for stabilisation of
the ribs are techniques following Robicsek (15), an
omentoplasty (16-18), pectoral muscle flaps or rectus
abdominis muscle flap (19, 20) to fill up the gap.
However, these techniques do not always guarantee
stability due to excessive bone loss after mediastinitis
and the former debridement. Refixation with wires is
then not always efficient and sometimes even impossi-
ble. With the refixation system, the osteosynthesis relies
on the strength of the ribs, and no longer on that of the
The transverse plate system is easy to handle, safe and
efficient, but the time of surgery is longer compared with
simple rewiring (range 120-150 minutes). It is also rela-
tively expensive and therefore not a routine technique for
treatment of every sternal instability.
The titanium transverse plate fixation system is a very
promising adjunct to the armamentarium of cardio-
thoracic surgery for treatment of sternal problems. This
technique should be taken into consideration when the
sternum shows important and persistent dehiscence, with
one or more sternal fractures and for refixation after
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Titanium Transverse Plate Fixation Download full-text
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Prof. Dr. I. Rodrigus
Department of Cardiac Surgery
Antwerp University Hospital
B-2650 Edegem, Belgium