Traumatic fracture of nitinol thermoreactive sternal clips

Jack Broadhurst, Narain Moorjani and Sunil Ohri

Interact CardioVasc Thorac Surg 2010;10:465-466; originally published online Dec 9,
2009;
DOI: 10.1510/icvts.2009.218867

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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Interactive Cardiovascular and Thoracic Surgery is the official journal of the European Association
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doi:10.1510/icvts.2009.218867

Editorial
New Ideas
Interactive CardioVascular and Thoracic Surgery 10 (2010) 465–466
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Case report - Cardiac general

Progress Report
Traumatic fracture of nitinol thermoreactive sternal clips

Work in
Jack Broadhurst, Narain Moorjani*, Sunil Ohri
Department of Cardiothoracic Surgery, Southampton General Hospital, Southampton, SO16 6YD, UK

Protocol
Received 11 August 2009; received in revised form 10 November 2009; accepted 17 November 2009

Abstract

Institutional
Report
Median sternotomy can be associated with significant morbidity, including non-union, dehiscence and mediastinitis. The use of flexible
thermoreactive sternal clips has been introduced recently as an alternative method of sternal closure and is advocated in patients at
increased risk of sternal breakdown. It is associated with a decreased incidence of sternal complications as well as allowing faster sternal
closure and easy removal on resternotomy. This report describes the case of a fractured thermoreactive clip following trauma, resulting in

Article
sternal dehiscence necessitating sternal rewiring.

ESCVS
䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Thermoreactive sternal clips; Sternal closure

Proposal for Bail-

out Procedure
1. Introduction with chronic stable angina. Cardiac catheterisation dem-
onstrated severe three-vessel coronary artery disease. He
Complications of median sternotomy include non-union,
underwent coronary artery bypass grafting surgery, includ-

Negative
dehiscence, mediastinitis, superficial wound infection and

Results
ing the use of the left internal mammary artery. In view of
fistula w1x. Following cardiac surgery, sternal wound com-
his age, comorbidities and markedly osteoporotic sternum
plications occur in ;2–5% of patients w2x. There are mul-
observed intraoperatively, the sternum was closed using
tiple risk factors for these complications including obesity,
nitinol thermoclips. Interrupted stainless steel wires were

Follow-up
diabetes, renal impairment, chronic obstructive pulmonary

disease, steroids, advanced age, osteoporosis, smoking and
harvesting bilateral internal mammary arteries w3, 4x. Rou-
tine closure of median sternotomy in adults usually involves
Paper
initially placed in the manubrium and a single wire placed
inferiorly just above the level of the xiphoid process to
achieve sternal approximation. Electrocautery was then

5–9 interrupted stainless steel wires used to achieve osse-
ous apposition of the two hemisternums. The pressure point
of contact during the closure is determined by the diameter
of the wire. If bony apposition is not exact or if there is
excessive movement, such as in patients with lower respi-
State-of-the-art
used to create a passage through the 3rd, 4th and 5th
intercostal spaces immediately adjacent to the sternal
edge, taking care not to injure the remaining right internal
mammary artery. Backaus forceps were placed into the
spaces to determine the size of each clip (ranging between

Best Evidence
ratory tract infections or chronic obstructive pulmonary 20 mm and 40 mm). The clips were placed in ice-cooled

disease, it is possible for the stainless steel wires to
‘cheesewire’ through the bone resulting in sternal dehis-
cence w5, 6x. Sternal closure using thermoclips, however,
distributes the pressure over a wider area as the clips have
a greater diameter at the point of contact w7x. Furthermore,
their thermoreactive properties allow the clips to be slight-
ly loose at insertion to allow accurate positioning followed
by auto-tightening induced by body temperature, ensuring
good osseous apposition. This report describes the use of
Topic
water to achieve temperatures -9 8C until they become
malleable. Following mounting on special insertion forceps,
the clips were placed in the intercostal spaces. Once in
situ, the clips then warm up to body temperature becoming Nomenclature
more rigid and conforming to the curve of the intercostal
spaces. The patient’s initial postoperative recovery was
uneventful. On the 7th postoperative day, he sustained a
fall and landed on the metallic edge of his bed, sustaining
direct trauma to the sternum. Clinical examination and
Historical

thermoreactive clips in a high-risk patient and a complica- chest radiograph (Fig. 1) confirmed sternal disruption with
Pages

tion of its use. fracture of the inferior thermoclip. In view of this, he

underwent reoperation where multiple fractures of the
2. Case report
sternum were observed with all four steel wires cut through
An 83-year-old man with a history of chronic obstructive the sternum. The inferior thermoclip (Fig. 2) was fractured
Communication

pulmonary disease and chronic renal impairment, presented with the middle clip dislodged but the superior clip still in
Brief

situ. In view of the multiple sternal fractures, the sternum

*Corresponding author. Tel.: q44-(0)2380-794938; fax: q44-(0)2380-
794256. was reunited with steel wires in a figure-of-eight configu-
E-mail address: narain.moorjani@doctors.org.uk (N. Moorjani). ration. The patient was discharged two weeks after the
Case Report

䊚 2010 Published by European Association for Cardio-Thoracic Surgery

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 ARTICLE IN PRESS
466 J. Broadhurst et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 465–466

encircle the sternum, unlike sternal wires, and they possess

a greater degree of flexibility, they allow a 10–15% defor-
mation in shape during vigorous coughing w4x. At body
temperature, the rigidity of the thermoclips means that
when exposed to a high energy impact above a certain
tensile force, the clips may fracture. These forces are,
however, rarely exerted on the sternum and in our experi-
ence when applied, they also result in fracture of the
sternal wires and sternal bone itself. Nitinol also has many
physical advantages over stainless steel, in that it is more
stable, less corrosive and more biocompatible. Further-
more, unlike stainless steel wires, the nitinol thermoreac-
tive clips do not integrate into bone and being non-
ferromagnetic are safe to use in magnetic resonance imag-
ing w7x.
Although these thermoreactive clips can be used in most
situations, they were not used in this patient at the second
operation as the sternum had multiple fractures. In this
situation, there was no rigid foundation for the thermoclips
Fig. 1. Chest radiograph demonstrating the dislodged thermoclip (A) and the
fractured inferior thermoclip (B).
to bind.
In summary, the use of thermoreactive nitinol clips is an
effective technique for sternal closure but this case report
demonstrates that when high impact forces are applied to
the sternum, the thermoclips can fracture. One of the
sternal clips, however, was still able to remain intact even
when all the sternal wires and the sternal bone were
fractured in several places.

References

Fig. 2. Intact superior thermoclip (a) and fractured inferior thermoclip (b).
second procedure with no further complications and
remains well at six months follow-up.
3. Discussion
Sternal dehiscence following median sternotomy can have
a major impact on health service resources and patient
survival w1, 3x. Nitinol thermoreactive clips have been
shown to reduce the incidence of sternal complications w4,
7, 8x. Nitinol sternal clips (Nickel Titanium Naval Ordinance
Laboratory, Praesidia, Bologna, Italy) are characterized by
shape memory and superelasticity. They become malleable
at -9 8C and then by thermoelastic martensitic transfor-
mation return to their original shape when warmed to body
temperatures, thereby able to apply compressive forces
on the two hemisternums w7x. As the clips do not fully
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 Traumatic fracture of nitinol thermoreactive sternal clips
Jack Broadhurst, Narain Moorjani and Sunil Ohri
Interact CardioVasc Thorac Surg 2010;10:465-466; originally published online Dec 9,
2009;
DOI: 10.1510/icvts.2009.218867
This information is current as of April 6, 2010

Updated Information including high-resolution figures, can be found at:

& Services http://icvts.ctsnetjournals.org/cgi/content/full/10/3/465
References This article cites 8 articles, 6 of which you can access for free at:
http://icvts.ctsnetjournals.org/cgi/content/full/10/3/465#BIBL
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