# Sternal Closure After Clamshell Thoracotomy for Bilateral Lung Transplantation: Comparison Between Different Techniques

## TL;DR

This study compares different methods for closing the sternum after lung transplants, finding that crossed wired sutures reduce misalignment and postoperative pain.

## Contribution

The study identifies crossed wired sutures as a superior technique for sternal closure after clamshell thoracotomy in lung transplantation.

## Key findings

- Crossed wired sutures (CWS) had a significantly lower sternal separation rate (9.1%) compared to other techniques.
- Patients with sternal separation experienced higher pain scores on postoperative day 7.
- Higher BMI was associated with increased risk of sternal separation.

## Abstract

Clamshell thoracotomy is a common approach for bilateral lung transplantation; however, after chest closure, the 2 sternal ends may not reapproximate properly. We aimed to assess the efficacy of different techniques of sternal closure in determining a correct sternal alignment postoperatively.

We performed a single-centre retrospective review of all patients who underwent bilateral lung transplantation through clamshell thoracotomy from 2016 to 2023. Patients were divided according to the sternal closure technique into the figure-of-8, resorbable suture (FRS), interrupted wired sutures (IWSs), and crossed wired sutures (CWSs) groups. Sternal alignment was evaluated on lateral chest X-rays and scored as normal, override, or separation.

Of the 164 eligible patients, the FRS, IWS, and CWS groups consisted of 44, 10, and 110 patients, respectively. Sternal separation was observed in 31 patients (18.9%), and its rate was significantly lower in the CWS group (9.1% compared to 40.9% and 30.0% in the FRS and IRS groups, respectively, P < .001). At multivariable analysis, increasing body mass index was associated with higher risk of sternal separation (odds ratio [OR]: 1.13, 95% confidence interval [CI]: 1.02-1.27), while the CWS technique was associated with a reduced risk (OR: 0.14, 95% CI: 0.06-0.34). Patients with sternal separation had significantly higher pain scores on postoperative day 7 and a trend towards significantly higher pain scores on postoperative day 14 (P = .056).

In our study, the CWS technique led to better sternal alignment than other techniques and should be the preferred method of sternal closure after clamshell thoracotomy. Severe sternal misalignment is associated with higher pain scores early after transplantation.

Lung transplantation represents the last therapeutic option for patients with end-stage pulmonary disease, offering significant improvements in both survival and quality of life.