Background: Sterile sternal nonunion after sternotomy during cardiac surgery occurs less than five percent in our institution. We have defined sterile nonunion as symptoms of sternal pain in conjunction with clicking and instability for more than three months duration in the absence of infection. There are multiple techniques used to achieve closure of complicated median sternotomy wounds, the most common being operative rewiring. However, simple rewiring alone has not proven to be sufficient when nonunion is complicated by the presence of multiple transverse fractures or in patients with large chest diameters and associated pulmonary disease. Consequently, we have found sternal plating advantageous in treatment of these patients and alleviating their symptoms by achieving a stable thoracic cavity.
Methods: This is a retrospective review of office charts and hospital records of all patients who underwent transverse titanium plate fixation with myocutaneous pectoral advancement flap closure. Demineralized bone graft was used when adequate bone to bone contact could not be uniformly achieved throughout the sternotomy incision. We indentified five patients in whom the procedure was performed between 2007-2009. Documented office follow-up is up to fifteen months postoperatively. All patients had multiple coronary artery bypass grating, were obese, and had associated pulmonary disease requiring medication. Diagnosis of sterile nonunion was made between five and sixteen months after cardiac surgery.

Results: The five patients reviewed had favorable outcomes. Mean operative time was 129 minutes. Prior to sternal plating the majority of patients required narcotic medication to control the painful sternal click. Early postoperative course was uneventful. All patients were discharged between one and three postoperative days and there were no readmissions for complications relating to the procedure. There was no incidence of subsequent infection requiring outpatient treatment. Bone healing was assessed clinically with no evidence of instability or clicking. No patient required narcotic relief of pain after the initial postoperative period. All patients reported no limitation of activity relating to their sternal incision and stated that they had an improved quality of life.
Conclusion: Transverse sternal plating system with bilateral pectoralis advancement flap is an effective treatment for sternal nonunion. This technique requires minimal dissection of the posterior sternal border, which allows for a secure wound approximation. For sternal wounds complicated by multiple rib fractures, chronic instability and/or poor bone quality, sternal plating is an ideal alternative to wire closure and has become our first choice in treating this debilitating condition.