Results:
The retrospective cohort included 283 patients who underwent refixation due to NSID after median sternotomy. The patients had a mean age of 58.5±13.4 years (range, 33–82 years) at reoperation and a male (n=176) to female (n=107) ratio of 1.64. The mean interval between the initial operation and the sternal reoperation was 49.4±9.5 days (range, 42–78 days).
Our study mainly consisted of 34 patients who were treated with the TRNC method due to NISD after median sternotomy. Demographic, preoperative, intraoperative, and postoperative variables of patients who had a previous failed Robicsek procedure before the TRNC method (group A, n=11), and patients who underwent the TRNC method immediately (group B, n= 23), are presented in Table 1. The mean interval between failed Robicsek procedures and TRNC treatment was 18.4±2.6 days (range, 14–26 days) in group A (n=11).
Initial procedures included: 58.8% coronary artery bypass grafting (20/34), 11.7% valve replacement (4/34), 5.8% repair of ascending aorta (2/34), and 23.5% combination of procedures (8/34). There was no significant difference in terms of initial procedure requiring median sternotomy between the analyzed groups.
The mean hospitalization time after TRNC treatment was 9.3±3.2 days (range, 5–24 days). The mean operative time was 56.4±8.4 minutes (range, 40–95 minutes) and the mean blood loss was 312.4±76.6 ml (range, 150–1000 ml).
There was no significant difference between the groups in terms of comorbidity rates or surgical complications. Risk distribution according to group A and B, including comorbidities and surgical complications, is presented in Table 2. Both groups consisted of high-risk patients.
Postoperative complications included: chronic ventilator dependence or intubation for more than 7 days (2.9%, 1/34), pneumonia (5.8%, 2/34), hematoma (8.8%, 3/34), seroma (14.7%, 5/34), pleural effusion (8.8%, 3/34), delirium (11.8%, 4/34), atrial fibrillation (8.8%, 3/34), and severe limitations of physical activity due to excess sternal pain (26.4%, 9/34). Postoperative superficial sternal infection was seen in 5.8% of TRNC patients (2/34), but none of the superficial infections progressed into the mediastinum. No mortality was reported. A detailed comparison of post-operative complications between the analyzed groups is presented in Table 3. Postoperative complication rate was significantly higher in group A (p=0.026). Hospitalization duration was significantly longer in group A, due to the higher complication rate (p=0.001). Operative time was significantly shorter and blood loss was significantly lower in group B (p=0.001).
After TRNC treatment, sternal stability at hospital discharge was reached in 94.1% of the patients (32/34). Two cases in group A still had sternal dehiscence (2/11), whereas all patients in group B had sternal stability at the time of discharge (p=0.035).
In addition, we compared the results of group B and group C. High-risk patient frequency was significantly higher in TRCN group (group B) compared to Robicsek group (group C) (100% vs 6.5%) (p=0.001). Overall success rate of Robicsek repair was 93.8% (244/260) and TRCN was 100% (p>0.05) but the success rate of the Robicsek repair in high-risk patients with NISD (n=17) was 35.3% (6/17). TRCN treatment was significantly more effective in high-risk NISD patients compared to Robicsek repair with a success rate of 100% (p=0.01). Lastly, operative time was significantly shorter in group B compared to group C (47.3±7.6 vs 75.3±4.8) (p=0.01). There was no significant difference between the groups in terms of age, gender, blood loss, complication rate, ICU stay or hospital stay (p>0.05).