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Critical Reviews™ in Biomedical Engineering
SJR: 0.243 SNIP: 0.376 CiteScore™: 0.79

ISSN Print: 0278-940X
ISSN Online: 1943-619X

Critical Reviews™ in Biomedical Engineering

DOI: 10.1615/CritRevBiomedEng.2019026454
pages 59-99

Rationale and Options for Choosing an Optimal Closure Technique for Primary Midsagittal Osteochondrotomy of the Sternum. Part 3: Technical Decision Making Based on the Practice of Patient- Appropriate Medicine

Harjeet Singh Gandhi
Hamilton Health Sciences, Suite 515, 644 Main Street West, Hamilton, Ontario, Canada L8S 1A1


The topographic anatomy of the sternum is similar in a healthy population. However, in a clinical subset of patients with comorbidities such as diabetes mellitus, chronic obstructive pulmonary disease, high body mass index, chronic renal disease, or age-related osteoporosis, there are significant changes in the normal physiology that may influence overall patient outcome following trans-sternal intrathoracic surgery. These changes can create technical difficulties in reconstructing the bisected sternum and adversely affect the biomechanics of the thoracic wall, forcing difficult surgical choices with regard to implant options and increasing the cost of an otherwise routine cardiac surgery. A thorough preoperative surgical and technical planning is essential to avert perioperative complications such as failure of wound healing, non-union of the sternum, and life-threatening mediastinitis. Patient expectations need to be explored and the patients should be well informed so that they can make knowledgeable choices regarding their illness and surgical interventions. They should also be given a probable prognosis to provide psychological support. Within the realm of clinical methodology, the concept of patient-appropriate medicine is introduced to direct attending team to become aware of overall health of its patient. The inclusion of a clinical biomechanical engineer as a surgical team member is recommended to perform patient-specific finite element analysis to select an optimal implant to fix the sternum. To help assess the overall benefit–risk profile objectively, an absolute therapeutic index has been proposed.

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