Rigid Fixation help?

[thos_huxley]

I'm just 10 days from my AVR surgery, after it got rescheduled from Feb. 7. During my pre-procedure consult with my surgeon (Dr. Keith Allen, St. Luke's Hospital in Kansas City), I asked if he could close my sternum with the Sternaloc Blu rigid fixation system. I knew he was PI for this, and of course he agreed to use it.

In clinical tests it's been found to result in faster and less frustrating post-op recovery with fewer complications, but I've only been able to find professional journal articles about it. Has anyone here gotten this type of closure and, if so, how did it go? Is there anything in particular I should be aware of, and what degree of mobility should I expect?

Thanks in advance!

 

[tom in MO]

I had my surgery done by Dr. Allen at St. Lukes. He and his team did right by me. I also did St. Luke's cardiac rehab and found it helpful. I still do some of the exercises I learned ~10 years ago.

Per your question, I believe there is at least one historical post on this board. It was positive.

 

[Zoltania]

Here's one historical post:

Intense Pre-Op Testing Day

 

[pellicle]

but I've only been able to find professional journal articles about it.

when you search, how do you search?

First links:

https://core.ac.uk/download/pdf/212970436.pdf
https://core.ac.uk/download/pdf/212994357.pdf
https://www.dl.begellhouse.com/journals/4b27cbfc562e21b8,360872d751cec21c,5f6cdca467c74ad4.html
I would ask a quick question: why has basically nobody else used it in the last X years?

They seem to have FDA approval

 

[thos_huxley]

when you search, how do you search?

I would ask a quick question: why has basically nobody else used it in the last X years?

I would strenuously disagree that "basically nobody else use it." My reading suggests it's in fairly wide use in the US, and that it's been well-evaluated with postive results.

As a retired professor with university library privileges, I use Health Source Academic, ProQuest Allied Health, CINAHL Plus, and Medline for stuff that's not available via Google Scholar or without a subscription. What I haven't found much about is how patients experience recovery with these devices, and what mobility restrictions apply.

Here's what I've got:

https://pubmed.ncbi.nlm.nih.gov/27923485/https://pubmed.ncbi.nlm.nih.gov/23103010/https://pubmed.ncbi.nlm.nih.gov/30505745/https://trialbulletin.com/lib/entry/ct-03709693

 

[thos_huxley]

(Don't ask me how all that got struck out. It just posted that way.)

 

[pellicle]

(Don't ask me how all that got struck out. It just posted that way.)

Well that not withstanding, if less than one percent of operations globally use it, then "to all intents and purposes" almost nobody is using it.

Meaning it's experimental. Not that it's not good.

Also, once you have seen an error you can edit it to rectify it.

 

[Unicusp]

Before my surgery, I inquired about using this with my surgeon (Lars Svensson). It was a very brief conversation. He said no. He believes in tried and true methods. This is novel and adds unnecessary complexity.

 

[pellicle]

He said no. He believes in tried and true methods. This is novel and adds unnecessary complexity.

on this point I would say (from where I sit both educationally and experientially) that dealing with an infection hiding behind that plate and having all those crevices to hid in would be a nightmare.

 

[pellicle]

(Don't ask me how all that got struck out. It just posted that way.)

PS, I'd say this had something to do with it

I speculate that after you typed "use" you pressed Ctl+S instead of simply "s".

as mentioned its a simple fix

Oh and on this point: " but I've only been able to find professional journal articles about it. " ... that is what you want to be looking for, not fluff. I read quickly in my initial reply and incorrectly intrepreted that as "unable to find ..."

My mistake there

 

[pellicle]

Ok @thos_huxley
my reading interpretations go like this:
https://pubmed.ncbi.nlm.nih.gov/27923485/
no statement about the patient age group (probably the single largest factor), methods or any details. Single blinded is a bit worrysome especially from the ethical stand point. I would hope they were informed of being part of a trial.

Sternal wound infections is a bit unclear and I can say that my sternal wound came up at 1 year (which is apparently what my bacteria does). The question would be (to me) "what influence in process caused the 4% sternal wound infection" in the "standard model"

on to:
https://pubmed.ncbi.nlm.nih.gov/30505745/
they make the point: " Rigid plate fixation (RPF) is the cornerstone in managing fractures and osteotomies except for sternotomy " which is interesting because a key aspect of the sternum is that it is by nature not rigid but flexible. I suspect that anatomical aspect may be being quietly ignored (because its well known and yet isn't addressed)

Also seems to be a re-hash of the same patient set data because both are:
"Twelve US centers randomized 236 patients to either RPF (n=116) or WC (n=120). The primary endpoint, sternal healing at 6 months" meaning that this is not a repeated experiment / study

https://pubmed.ncbi.nlm.nih.gov/23103010/
again nothing about the age spread of the patients, this is critical data because elderly (I don't know your age , NB I just checked, its 67) have higher problems in this and also I would venture less need of flexibility of that bone as someone in their 40's who is still physically active. (so with that above knowledge then if you aren't still doing something like Aikdo or Judo or some flexibility requiring sport) only the post surgical performance and infection issue would be significant issues.

On this point: " Significant differences in pain scores were observed at 3 weeks for total pain (p=0.020) and pain with coughing (p=0.0084) or sneezing (p=0.030). Complication rates were similar in both groups. "
I would venture that on a surgery which should have a 10 years or longer benefit window that "pain in the first 3 weeks" is incidental.

What we don't see is follow up in 2, 5 or 10 years. But then we seldom do with these sorts of experiments.

So, all things considered, I'd say: it depends on how you feel about being a lab experiment for someone's hobby barrow.

Last point, the poster mentioned in the above thread from here was not a young looking man, so the benefits for an older man (or woman) may indeed be better than for a younger man (or woman). I note that he has ventured here recently (history) ... why not reach out with a PM and ask his views? Perhaps (with a mention of @skeptic49 ) he may indeed post here his personal experience in his time post surgery).

Best Wishes

 

[thos_huxley]

Ok @thos_huxley
my reading interpretations go like this:

Considering your personal experience with sternal dehiscence due to wire cerclage, this argument against sternal fixation is pretty weak tea. In my case, I'm not eager to endure the restrictions, precautions, inconvenience, and time to heal associated with a dated closure technique. After all, orthopaedic surgeons have been implanting a variety screws, plates, and orthotic devices in patients for years. A very good (and older) friend has had two knee replacement surgeries. He's fine. I see no difference between that and rigid sternal fixation.

"Lab experiment for someone's hobby barrow"? Oh, c'mon. Every individual subscribing to this board is engaged in a personal experiment between life and death, disability and freedom. Traveling in a pressurized aluminum tube at 30,000 feet is an experiment in risk; maybe it'll end in catastrophe, but it probably won't. At some point we must step into the unknown, place our lives in the hands of someone else, or a technology we don't control, and make a calculation. Which surgeon? Which hospital? Tissue or mechanical? What manufacturer? TAVR or SAVR? Wires or plates? Good grief.

As for me, I'm impressed by the results of the studies I've read. I trust the opinions of my surgeon and cardiologist. Both are extremely competent, work at a high-performing hospital, and have many years of experience. I trust their professional advice regarding my health, and know they would not intentionally make a perilous decision about it.

In any event, here's some additional reading for your consideration, that may improve your appreciation of this technique:

https://www.annalsthoracicsurgery.org/article/0003-4975(91)90910-I/pdfhttps://www.criticalcare.theclinics.com/action/showPdf?pii=S0749-0704(20)30045-2https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0036-1583297https://journals.lww.com/annalsplas...on_for_the_Prevention_and_Treatment_of.8.aspxhttps://academic.oup.com/icvts/article/5/4/336/671887https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3134981/pdf/TOCMJ-5-148.pdfhttps://www.annalsthoracicsurgery.org/action/showPdf?pii=S0003-4975(18)30017-1
(And, thank you for setting me straight about my formatting issue. Appreciate. It appears some of the URLs above don't translate well. But they'll get you there.)

 

[pellicle]

Considering your personal experience with sternal dehiscence due to wire cerclage

Well you got that wrong right there.

 

[thos_huxley]

Well you got that wrong right there.

Sorry, but that's what it looks like to me. You have, I believe, mentioned bacterial infection growth along sternal wires.

 

[pellicle]

Sorry, but that's what it looks like to me. You have, I believe, mentioned bacterial infection growth along sternal wires.

given your approach and you lack of actual engagement I'm not going to waste my time further on this. Considering you equate a Knee replacement with a sternum I feel that any conversation will be a waste of my time. Heck you didn't even acknowledge my critical analysis of the first trio of papers. Instead you just acted like a salesman and furnished even more support.

You seem to have sold yourself on a system and found one of the (what? 5 surgeons?) in the USA who use it. You seem to be (as I wrote) old enough to not need upper body flexibility afforded by the sternum so the choice will probably be a good one for you.

So rather than assume what I had (which was well documented) you could have asked. But you'd already decided. So here's some reading and you can join the dots

https://en.wikipedia.org/wiki/Debridement
https://en.wikipedia.org/wiki/Wound_dehiscence
don't bother replying to me now.

Best Wishes

(ploop)

 

[tom in MO]

...You seem to have sold yourself on a system and found one of the (what? 5 surgeons?) in the USA who use it...

Dr. Allen was my surgeon and if he believe it's good to go, so would I. He really cares about the patient's total experience including the size of the scar and after operation care. Unlike you he is a cardiac surgeon with lots of experience in the prime of his career.

Just because a new method is not widely adopted doesn't mean it's flawed, it could be better. If a surgeon is "risk adverse" they would avoid anything they don't know due to the US's litigious society. If the price is high it may not be allowed by many insurance companies.