This is initial data from the Figure 8 FlatWire Sternal Closure System. FlatWire is a simple, strong, and cost effective replacement for traditional steel wire for sternal cerclage.
Despite the advances in wire technology and development of algorithm-driven methodology for chronic
total occlusion (CTO) intervention, there is a void in the literature about the technical aspects of CTO wiring.
The Asia Pacific CTO Club, a group of 10 experienced operators in the Asia Pacific region, has tried to fill this
void with this state-of-the-art review on CTO wiring
Biomechanical Investigation of Plate Working Length on Fatigue Characteristics of Locking Plate Constructs in Human Cadaveric Distal Metaphyseal Femoral Fracture Models
Despite the advances in wire technology and development of algorithm-driven methodology for chronic
total occlusion (CTO) intervention, there is a void in the literature about the technical aspects of CTO wiring.
The Asia Pacific CTO Club, a group of 10 experienced operators in the Asia Pacific region, has tried to fill this
void with this state-of-the-art review on CTO wiring
Biomechanical Investigation of Plate Working Length on Fatigue Characteristics of Locking Plate Constructs in Human Cadaveric Distal Metaphyseal Femoral Fracture Models
Percutaneous Pedicle Screw Fixation For Thoracolumbar injuries using a low co...Ansarul Haq
The goal of PPSI is to decrease the trauma associated with the standard open approach, which can lead to significant devascularization and denervatation of the paraspinal musculature. This tissue trauma may be a contributing factor to patients’ chronic pain after surgery
Ann Vasc Surg 2012; 26: 141-148-Selected technique- Funnel Technique for EVAR: ‘‘A Way Out’’ for Abdominal Aortic Aneurisms With Ectatic Proximal Necks
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
NJR data reports that the majority of surgeons use a cemented stem for hemiarthroplasty in fractured neck of femur patients. For those that use an uncemented implant this simple tool can help predict those patients in whom the risk of fracture is high and where a cemented implant should be further considered.
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts wi...CrimsonPublishersOPROJ
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts with Femoral Suspensory Fixation: A Biomechanical Study by Matthew Richard Moralle* in Crimson Publishers: Orthopedic Research and Reviews Journal
Surgical Management for a Stuck up and fracture angioplasty devices in Vivo during PCI in a Complex LAD Artery Lesion: A Case Report and Literature Review.
Md. Abir Tazim Chowdhury1, Sohail Ahmed2, Md. Zulfiqur Haider2
Abstract
Background: Stuck up and fracture of coronary angioplasty devices are uncommon complications of percutaneous coronary interventions (PCI) for which surgical rescue and management is once in a while needed.
Case description: Here, we present one case of a 59-year-old diabetic, a hypertensive gentleman, who attended the emergency room (ER) with central chest pain for several hours and, after physical and diagnostic evaluation, was diagnosed as a case of Acute ST-segment elevated Myocardial Infarction (AMI) with stable hemodynamic. The findings mentioned above were initially treated with the thrombolytic agent in the ER and followed by admission to the cardiac care unit for monitoring and further invasive coronary evaluation by coronary angiogram (CAG). It was demonstrated essentially Single Vessel Disease (SVD) with complex Left Anterior Descending (LAD) artery lesion, where PCI attempted but failed with unfortunate stuck up and broken of the delivery shaft, and left inside the coronary system. Immediate judgment and surgical retrieval of lost angioplasty device and correction of the coronary lesion with its revascularization save the patient life from grave complications. This article describes all the critical, challenging events and our management approaches to this very complex coronary artery lesion.
.
Conclusion: Coronary angioplasty hardware should be regulated gently, carefully, and precisely according to the manufacturers' instructions for use, and it should be inspected for its integrity once brought out of the patient's body. In vivo trap of angioplasty hardware, fracture, and retention during the PCI are infrequent. Percutaneous retrieval of specifically complex bifurcation lesions constantly presents limits and risks. In those cases, it will be crucial to thoroughly inform the patient concerning the hazard of the procedure and consider surgical revascularization.
Address of Correspondence:
Name: Dr. Md. Abir Tazim Chowdhury
Designation: Specialist, Department of Cardiothoracic and Vascular Surgery
Institution: Evercare Hospital Dhaka, Bangladesh.
e-mail: chowdhuryabir0@gmail.com
Utility of balloon assisted technique in trans catheter closure of
very large (≥35 mm) atrial septal defects
Ajith Ananthakrishna Pillai, Vidhyakar Rangaswamy Balasubramanian, Raja Selvaraj, Maheshkumar
Saktheeswaran, Santhosh Satheesh, Balachander Jayaraman
A professional Nitinol manufacturer will take you to study the safety performance of the self-expanding Nitinol stent. For more knowledge about Nitinol, please follow us:https://www.nitinol.vip/blog/
A sample of my pitch-deck writing and related market research for a revolutionary and next-generation micro cardiovascular stent, which incorporates nanotechnology, MEMS, computer controlled surgery algorithms, and MRI. I conducted this work for a client, an inventor and scientist who gave me permission to make this sample public.
The temporal branch of the facial nerve is a commonly injured nerve during facial trauma due to its superficial course over the zygomatic arch, and is a commonly damaged nerve during facial surgery.1 We report a case of trauma to the left temporal fossa, and subsequent unilateral forehead paralysis. Early exploration revealed external suture compression as the origin of his paralysis. Removal of the suture led to complete resolution of the neurological deficit. The differential diagnosis did not include the possibility of the compression of the nerve by a suture, however the decision for early exploration led to a full recovery.
We report a case of acquired anterior thoracic lung herniation in a 63-year-old female. This painful herniation developed four years after uncomplicated video-assisted thoracic surgery for lung cancer resection and adjuvant radiation for concomitant breast cancer. The herniation site was remote from all prior incisions, and demonstrated intercostal muscle denervation and radiation fibrosis. The 8 cm x 10 cm chest wall defect was reconstructed with inlay PROCEED mesh and reinforced with a pedicled latissimus dorsi flap. Five months postoperatively the patient had complete resolution of symptoms, no evidence of herniation, and a stable wound.
This is a CME article that appears in Plastic and Reconstructive Surgery, the gold standard of publications within the field. Reconstructing the eyelid can be difficult and complicated. This article discusses the various approaches to defects caused by cancer.
This is a pilot study which examines the use of the fistbump instead of a traditional handshake in the hospital setting. In the hospital we use automatic doors, automatic sinks, and alcohol based hand sanitizer. However the rise of antibiotic resistant bacteria continues to increase. We propose ceasing handshaking within the hospital and opting instead for the fun fistbump will reduce the transmission of bacteria.
This is a paper that Dr. W. Thomas McClellan co-authored on the anatomy and reconstruction of the inframammary fold. This critical structure is often injured during breast augmentation and understanding of the anatomy is crucial to a good outcome in breast augmentation.
This is a powerpoint presentaiton given by W. Thomas McClellan, MD FACS, a Board Certified Plastic Surgeon who specializes in breast augmentation. This presentation is unique and critical because it gives patients detailed information about what is important regarding breast augmentation. For example: How to choose a surgeon, what is important in the operating room, postoperative care, how to pick a size, type of breast implant.
This is a paper which describes an innovative approach for skin sparing mastectomy. This incision tends to distract the eye and be less noticeable. Additionally it allows excellent access to the axilla for lymph node sampling and reduces the excessive retraction on the skin flaps.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
How to Give Better Lectures: Some Tips for Doctors
Prospective Pilot Study: Figure 8 FlatWire Sternal Closure System
1. RESEARCH ARTICLE
Prospective, randomized, single blinded pilot study of a new
FlatWire based sternal closure system.
Boustany, A. Ghareeb, P., Lee, K.,
West Virginia University, Division of Cardiothoracic Surgery Morgantown WV
ABSTRACT
Unstable steel wire cerclage following open heart surgery may result in increased
pain, sternal cut-through, non-union, or dehiscence. These complications lead to longer
hospital stays, increased cost, higher morbidity, and patient dissatisfaction. The Figure 8
FlatWire Sternal Closure System is a new construct which is a simple, intuitive, and
inexpensive alternative for primary sternal repair following open heart surgery. Prior
bench-top testing of FlatWire has demonstrated superior strength and stiffness compared
to traditional steel wire. We present our initial experience in a prospective, randomized,
single blinded pilot study utilizing this FDA cleared system.
Sixty-three patients undergoing elective cardiac surgery via complete median
sternotomy at a single institution were randomly assigned to receive either the Figure 8
FlatWire or standard steel wire cerclage. All surgeries were performed by a single board
certified cardiothoracic surgeon. Data collected included: Age, BMI, pump time, off
pump to surgical stop time, length of hospital stay after surgery, cost from time of
surgery to discharge, and pain on a visual analog pain scale on the day of discharge, day
30, and day 60.
The groups were well matched. Patients receiving the Figure 8 FlatWire (33) had
a reduction in length of stay compared to patients receiving steel wire cerclage (30), but it
was not statistically significant (6.8 vs. 7.8 days respectively, p<0.093). Additionally
those with the FlatWire reported significantly decreased pain at day of discharge (3.07 vs.
4.92 points on visual pain scale, p<0.0066), with similar pain scores at 30 and 60 days.
Off pump to surgery stop time was increased by 15.9 minutes in patients receiving the
FlatWire vs. steel wires (55.7 vs. 71.6 minutes, p=0.00025). Mean cost from surgery until
discharge was $87,820.98 in the FlatWire group vs. $91,930.29 in the steel wire group
(p<0.3082).
Early clinical results suggest that Figure 8 FlatWire provides excellent stability,
which resulted in significantly diminished postoperative pain at discharge. Although not
significant there was a trend toward decreased length of stay, and reduced cost. Further
clinical research is warranted to expand upon these initial trends and validate long term
outcomes.
INTRODUCTION
Closure of the median sternotomy with steel wire has been used for more than 50
years18. However, the patient population undergoing cardiac surgery today has
1
2. dramatically changed over the last 20 years. Surgical candidates today present as older,
multi-morbid patients, with more serious cardiac disease. Advanced age, diabetes,
obesity, renal insufficiency, lung disease, osteoporosis, and poor nutritional status
compounded by more complex operations are commonplace18.
The consequences of sternal separation, cut-through, or dehiscence can be
profound, with a mortality rate of 10-40%1. The risk of complications increase in
complex patients and in the elderly2,3. Over 760,000 procedures requiring sternotomy are
performed every year, making complications a serious healthcare issue4,5.
The median hospital costs for patients developing sternal wound complications
following coronary bypass grafting (CABG) can be up to 2.8 times higher than for
uncomplicated patients (8). The Department of Health and Human Resources has
identified these complications as hospital-acquired events (HAC) for which hospitals
should not receive additional payment if the condition was not present upon admission.
The most important factor in the prevention of sternal events is a stable sternal
approximation following sternotomy 6,7. There have been many attempts to improve upon
the standard method of steel wire cerclage, but these systems have failed to gain
widespread adoption due to impracticality or excessive cost.
The Figure 8 FlatWire Sternal Closure System was developed to provide a
primary closure method that is superior to standard steel wire cerclage, while avoiding
the drawbacks of current wire alternatives. Prior bench-top comparison demonstrated that
FlatWire is significantly stiffer than standard wire both in a transverse configuration, and
crossed (“X”) or figure of 8 pattern. In addition, FlatWire demonstrated significantly
reduced cut-through and improved resistance to cyclic failure when compared to steel
wire cerclage8.
The authors hypothesized that the superior mechanical aspects of FlatWire would
translate into improved clinical outcomes by reducing post-operative pain, leading to
decreased length of stay and total cost.
TECHNOLOGY AND
TECHNIQUE
The
Figure
8
FlatWire is made of 316L
stainless steel. A stainless
steel needle is attached to
the flexible body of the
FlatWire.
The
body
sequentially widens to
2.8mm which facilitates
delivery around or through
the sternum. It comes
packaged as a complete
surgical kit with eight
FlatWires and a reusable
Figure
1:
The Figure 8 FlatWire Sternal Closure System comes
packaged with 6 straight and 2 “X” designed FlatWires. A reusable
tensioning device is provided to apply to construct.
2
3. aluminum tensioning device (Figure 1).
A standard needle driver and wire cutters are also used for application. The
FlatWires have two distinct ends: a proximal end attached to the needle and a distal end
with a rotating central hub and laser
welded security box that can
withstand >1400N of force.
A needle driver is used to
feed the FlatWire around the
sternum while its supported in its
central arc to minimize kinking. The
needle is removed with standard
wire cutters and the FlatWire end is
fed through the security box. It is
temporarily secured and left in
position until remaining straps are
placed, working in a cephalad to
caudad manner (Figure 2).
Once the desired number
and configuration of FlatWires are
placed, the Figure 8 tensioning
instrument is used to approximate
the sternal halves. The tensioning
instrument has a custom built in Figure
2:
FlatWires positioned and tensioned around the
break away mechanism that sternum. Multiple configurations are possible.
prevents applied forces to exceed
300N. FlatWires are then tensioned
to the desired effect using tactile
feedback and visual cues. The strap is temporarily bent to 90 degrees to hold the sternal
position. At this point the closure is reversible by unbending the FlatWire. Once the
surgeon is satisfied with sternal approximation; the FlatWires are simply twisted 120
degrees, without tension, using the instrument and cut to 1 cm. The 1 cm end is folded in
half and down onto the sternum. Removal of FlatWire is very fast and performed with
standard wire cutters. FlatWires may be used in conjunction with or as a replacement for
standard steel wire in primary sternal closure.
METHODS
Institutional Review Board approved the protocol. Sixty-three patients scheduled
to undergo elective cardiac surgery via complete median sternotomy at a single institution
were randomly divided into two cohorts: one group received the Figure 8 FlatWire while
the other received standard steel wire cerclage (No. 7 gauge stainless steel wire, Ethicon
Ltd.). The patients were blinded as to which group they were in. The same board-certified
cardiothoracic surgeon performed each procedure, and the configuration of the closure
method was determined by surgeon’s clinical judgment. X-rays at day of discharge and
30 days confirmed alignment and placement (Figure 3).
3
4. Pain was measured on a 10 point visual analog pain scale at day of discharge, day
30, and day 60. Length of postoperative stay was recorded and total cost from surgery to
discharge was calculated. The time of surgical closure was collected as the
cardiopulmonary bypass pump off time to the surgery end time (recorded by anesthesia).
Complications were documented.
Statistical analyses were performed using SAS software (Version 9.2; Cary, NC);
a student t-test was utilized to compare pain scores and length of stay between the two
groups.
Figure
3:
FlatWires are trimmed after all are tensioned. X-rays at day of discharge and 30
days confirmed alignment and placement of sternal constructs.
RESULTS
A total of 63 patients underwent coronary artery bypass grafting with midline
sternotomy, 30 patients received traditional stainless steel wire sternal cerclage and 33
patients received FlatWires. Mean patient age, body mass index, and pump time were
about equal in both groups as seen in Table 1. In their respective groups an average of 6
traditional steel wires and 5 Flatwires were used to repair the sternum. Patients receiving
the Flatwires reported significantly reduced pain at day of discharge compared to the
steel wire cohort (3.07 vs. 4.92, p<0.0066). Pain scores were statistically equal at 30 and
60 days (p<0.149 and p<0.088, respectively). Patients receiving the FlatWires did have
shortened post-operative length of stay compared to those receiving steel wire; however,
this difference was not found to be statistically significant (6.85 vs. 7.9 days, p<0.093).
Bypass pump off to surgery end time was used as an estimation of sternal closure time.
Patients receiving the FlatWires had significantly increased closure time (74.39 vs. 56.39
minutes, p=0.00025). Total cost during the patients’ hospital stay was reduced on average
in the Flatwire cohort but this finding was not significant ($87,820.98 vs. $91,930.29,
4
5. p<0.3082). There were no perioperative complications attributed to FlatWire or standard
steel wire. Chest X-ray at 30 days showed no sternal abnormalities in either group.
Twenty-four of the 34 FlatWire patients were contacted by telephone at 1-year follow-up;
there were no complications reported.
Figure 8 FlatWire
Standard wires
P value
Age
64.1
64.7
0.409
BMI
30.42
29.43
0.238
Days: surgery to discharge
6.85
7.9
0.093
VAS discharge
3.07
4.92
0.0066
VAS 30 days
1.52
2.11
0.149
VAS 60 days
0.39
0.79
0.088
Pump Time
110.16
101.04
0.212
Time: Off Pump to Stop
1:14:39
0:56:39
0.00025
Cost: surgery to discharge
87820.98
91930.29
0.3082
TABLE 1: Statistical analysis of study results. (P < 0.05)
DISCUSSION
Complications following median sternotomy include infectious or noninfectious
dehiscence, mediastinitis, osteomyelitis, chronic sternal pain and non-union. Comorbid
patients often have poorer bone quality and impaired wound healing that make them
more susceptible to these complications, particularly those with diabetes, osteoporosis,
pulmonary disease or obesity. Physiologic loads sustained with coughing or valsalva may
be sufficient to cause dehiscence in this high-risk group16. The key factor is compromised
sternal stability by wire breakage, excessive shearing forces, or lateral displacement of
the sternal halves. The majority of dehiscence is caused by steel wires cutting through
sternal bone. Some physicians select more expensive and durable closure methods rather
than using the standard wire cerclage to avoid the unstable sternum12. Management of
dehiscence varies by severity but often requires surgical debridement, rewiring, rigid
plate fixation, or muscle flaps9.
5
6. Post-sternotomy pain syndrome was first described in 1985 by Weber and
colleagues, a condition most often caused by painful sternal wire sutures or protruding
wires. It has been shown to be relieved in 83% of sufferers upon wire removal13,15. Other
causes of post-sternotomy pain are sternal instability and, of course, cardiac ischemia.
Prospective and retrospective cohort studies have indicated that the incidence of noncardiac pain after sternotomy ranges from 7-28% 9,10,13. Pain onset may be immediate or
delayed and varies with comorbidities, closure technique and bone quality12.
Prior to initiation of this prospective pilot study, bench-top testing of Figure 8
FlatWires demonstrated statistically significant improvements in tensile strength, bone
cut-through, and pull-to-failure compared to standard wire cerclage8. In our pilot study,
FlatWires significantly reduced pain after sternotomy compared to standard wire closure
(p<0.0066). These findings are likely related to the superior mechanical properties of
rigid fixation and the reduced cut into the bone. A study by Wong et al., showed similar
results in patients receiving rigid sternal fixation as opposed to conventional wire closure,
as well as improved osteosynthesis at 3 and 6 months14. Decreased post-sternotomy pain
may ultimately reduce analgesic requirements, hospital stay, and allow patients to return
to daily activities sooner.
Although rigid plate fixation is also more stable and associated with less pain than
traditional steel wires, the cost is greater and the use of screws carries its own armory of
complications (injury to mediastinal structures, screw migration)12. In addition, rigid
fixation is contraindicated in patients with osteoporosis as good bone quality is required
for screw placement. Wire cerclage remains the standard among cardiovascular surgeons
despite disadvantages due its familiarity, simplicity, and low cost11. FlatWire is a less
expensive alternative to plates and other alternative methods of closure. This pilot study
showed the length of hospital stay was 6.8 days compared to 7.8 in the standard group;
however this was not statistically significant. As the sample size is expanded, results may
indicate an overall shorter hospital stay, which would ultimately reduce hospital costs.
Also, with a theoretical decrease in postoperative complications, hospital costs would be
significantly reduced. A study of 201 patients in a Midwest hospital found that patients
experiencing deep sternal infections stayed an additional 20 days in the hospital and
incurred bills greater than $20,000 in those who survived17. Lower analgesic
requirements secondary to reduced pain, earlier mobilization, or shorter recovery time
may additionally provide financial advantages.
Time off pump to the surgery stop was increased in the FlatWire group compared
to the control group by 15.9 minutes (p<0.00025) on average. Although this was not a
direct measurement of the time allotted for sternal closure it can be inferred that device
application time was also longer. As with any new technology, there is a learning curve
for physicians to become acquainted with a new device. It is reasonable to assume that
the time for device application is expected to decrease as surgeons become more familiar
with its use.
Statistically significant decreases in post-operative pain at discharge and a
potential reduction in length of hospital stay and cost support the need for further
research. Expansion of this trial is underway at additional centers in order to collect a
larger sample size and patient experience.
6
7. CONCLUSION
Prior biomechanical testing demonstrated superior strength and stiffness of the
FlatWire when compared to standard steel wire. The initial pilot study results suggest that
the Figure 8 Sternal FlatWire provides excellent in-vivo stability.
Patients in the FlatWire cohort experienced significantly reduced post-operative
pain at discharge. Number of hospital days and cost were decreased in the Flatwire group,
although not significantly. Sternal closure time was increased in the Flatwire group but
can be expected to decrease with surgeon familiarity and proficiency.
FlatWire is a simple, safe, and strong alternative to traditional steel wire primary
sternal closure.
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