About 700,000 patients undergo open heart surgery every year in the United States. Up to 3% of those patients suffer from poor healing of the breastbone after surgery.
In 1978, Dr. Stoney recognized a medical condition resulting from breast bone non-union. This occurs when a patient experiences discomfort or pain after heart or valve surgery. They may also notice a clicking sound, a feeling of instability, and difficulty participating in sports activities. If these symptoms continue after 3 months, most likely it is a sternal mal-union (breast bone non-union)
In some patients the discomfort may be related to scar sensitivity. However, if there is deep pain and clicking, it is most commonly related to incorrect healing of sternum, or breastbone.
During heart surgery thoracic surgeon split the breast bone, aka sternum, from top to bottom in order to perform surgery on heart or heart valves. Many thoracic surgeons still use steel wires, or cords, to put the chest wall together after the surgery. Traditionally cardiac surgeons place several steel wires across from right to left and back. When patients breathe, the chest wall expands to allow air in. This lateral motion and tension created by breathing muscles after the surgery can loosen the wires. If left unnoticed, it can lead to mal-union or non-union. Wired breast bone may not be strong enough to tolerate a higher level of activity in younger patients, as it allows a little movement between right and left sides.
Surprisingly, many affected patients do not report this condition to their heart surgeons. And when they do, it is not uncommon for heart surgeons to dismiss the concerns of the patient once they ensure that the pain the patient has after the surgery is non-cardiac in nature. Patients usually mention this issue to their primary care providers who have very little to offer besides advising them to wait longer for the breastbone to heal or Motrin for pain and swelling. Many patients experience episodes of severe anxiety and frequent hospital visits with complaints of repeated chest pain. Eventually, once the pain was proven to be non- cardiac, the patient is labeled as an unstable person and they end up on a variety of psychiatric, anti-anxiety, antidepressants, and narcotic medications or referred to pain management specialists and psychiatrists. At this point, a few of them are referred to a plastic surgeon.
Sternal non-union, or sternal instability, can also happen after car accidents, and after industrial injuries when the breast bone was broken and not properly secured.
The most accepted indications for sternal instability repair are chronic pain, clicking, grinding, feeling of chest wall moving incorrectly, limited activities of daily living, and changes in breathing pattern.
Before the surgery, a CT scan of the chest and X ray may be needed to diagnose the problem.
Many cardiothoracic surgeons still treat mal-union with repeated sternal wires. They place multiple figure eight wires, oblique wires, wrap them around the ribs, etc. Unfortunately, the repair with more aggressive wire placement produces more problems than it solves, because wires can either cut through the breastbone or dangerously limit blood supply. One of the more complicated wire techniques is Robicsek weave. A recent study showed 20% of the patients had chronic instability, 10% had chronic pain, and 14% needed another operation with this particular technique.
The latest advance in sternal repair is using plates and screws instead of wires. This is based on the same principle that all orthopedic surgeons use when they treat bone fractures.
Treatment of sternal non-union, mal-union, or instability is not complicated. The wires from the breast bone are removed and replaced with steel or titanium plates. As the result, the breast bones are more secure in a proper position. The friction between the bones from breathing is eliminated and can heal properly.
In most patients pain and discomfort of the breast bone improves quickly. Once the breast bone heals, patients can return to the activities they love, such as golfing, swimming, biking, etc.
The surgery is performed in the hospital under general anesthesia and takes about two hours depending on the complexity.
If you have had heart surgery or a traumatic injury to your chest in the past:
If you had open heart or valve surgery in the past, or if you had automobile or industrial accident that traumatized your chest wall and you experience breastbone discomfort, pain, clicking, instability, or feeling that your rib cage is not moving the right way after the surgery, call our office for consultation with our board certified plastic surgeon, Dr. Boris Volshteyn.
If you are currently scheduled for open heart or valve surgery:
The solution to your problem may be simpler and quicker than you might think. If you are scheduled for heart or valve surgery at one of our local institutions, please feel free to call us and we will gladly work with your cardiothoracic surgeon to use the latest chest wall stabilization methods possible, returning you to your daily life and favorite activities.
Call us today 732-641-3350
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