Comparative Analysis of Figure-of-Eight versus Interrupted Sternal Wire Closure: Assessing Pain, Sternal Stability, Wound Healing, and Early Functional Recovery in Cardiac Surgery Patients after Sternotomy
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Background: Median sternotomy is widely used in cardiac surgery, but postoperative pain, sternal instability, impaired wound healing, and delayed functional recovery remain clinically important concerns. The configuration used for sternal wire closure may influence early recovery, although comparative evidence regarding figure-of-eight and simple interrupted closure remains inconsistent. Objective: To compare early clinical and functional outcomes between figure-of-eight and simple interrupted sternal wire closure in adults undergoing elective cardiac surgery through median sternotomy. Methods: This prospective comparative observational study included 108 patients from two tertiary cardiac surgery centres, with 54 patients in each closure group. Postoperative pain was assessed using the Numeric Analogue Scale, wound healing using ASEPSIS, sternal stability using the Sternal Instability Scale, and functional recovery using the Barthel Index. Additional outcomes included operative duration, time to ambulation, duration of analgesic use, hospital stay, patient satisfaction, and 30-day readmission. Results: The groups differed at baseline in age and COPD prevalence. Unadjusted postoperative outcomes favored figure-of-eight closure, including lower pain (1.81±1.47 vs 4.76±1.48; mean difference −2.95, 95% CI −3.51 to −2.39), higher Barthel scores (91.78±4.39 vs 75.94±9.09; difference 15.84, 95% CI 13.10–18.58), earlier ambulation, shorter hospitalization, greater frequency of satisfactory wound healing, and greater frequency of SIS Grade 0. Thirty-day readmission was 0 versus 3 patients (p=0.243). Conclusion: Figure-of-eight closure was associated with more favorable early postoperative outcomes in this cohort. Because closure allocation was observational and important baseline differences were present, the findings should not be interpreted as establishing independent superiority of the closure technique without adjusted or randomized confirmation.
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1. Phoon PHY, Hwang NC. Deep sternal wound infection: diagnosis, treatment and prevention. J Cardiothorac Vasc Anesth. 2020;34(6):1602-1613. doi:10.1053/j.jvca.2019.09.019.
2. Morrell Scott N, Lotto RR, Spencer E, Grant MJ, Penson P, Jones ID. Risk factors for post sternotomy wound complications across the patient journey: a systematised review of the literature. Heart Lung. 2022;55:89-101. doi:10.1016/j.hrtlng.2022.04.013.
3. Song Y, Chu W, Sun J, Liu X, Zhu H, Yu H, et al. Review on risk factors, classification, and treatment of sternal wound infection. J Cardiothorac Surg. 2023;18(1):184. doi:10.1186/s13019-023-02228-y.
4. Robicsek F, Fokin A, Cook J, Bhatia D. Sternal instability after midline sternotomy. Thorac Cardiovasc Surg. 2000;48(1):1-8. doi:10.1055/s-2000-9945.
5. Chopko TC, Khan FW, Stulak JM. Taken for granted: an analysis of sternal closure techniques. Ann Thorac Surg. 2026;121(1):53-64. doi:10.1016/j.athoracsur.2025.07.055.
6. Dasika UK, Trumble DR, Magovern JA. Lower sternal reinforcement improves the stability of sternal closure. Ann Thorac Surg. 2003;75(5):1618-1621. doi:10.1016/S0003-4975(02)04988-3.
7. Ramzisham ARM, Raflis AR, Khairulasri MG, Min JO, Fikri AM, Zamrin MD. Figure-of-eight vs. interrupted sternal wire closure of median sternotomy. Asian Cardiovasc Thorac Ann. 2009;17(6):587-591. doi:10.1177/0218492309348948.
8. Abbas S, Gul S, Abbas A, Iqbal M, Khan TV, Khan J. Figure-of-8 sternal closure vs simple interrupted sternal closure in reducing sternal dehiscence in patients with coronary artery bypass grafting (CABG). Pak Heart J. 2017;50(2):71-76.
9. Aykut K, Celik B, Acikel U. Figure-of-eight versus prophylactic sternal weave closure of median sternotomy in diabetic obese patients undergoing coronary artery bypass grafting. Ann Thorac Surg. 2011;92(2):638-641. doi:10.1016/j.athoracsur.2011.04.034.
10. Mourad FA, Abd El Hameed WAS, Abd El Hameed HEDA, Mohamed MA. Sternal closure using steel wires by figure of eight versus interrupted simple sutures in adult cardiac surgeries. Ain Shams Med J. 2020;71(4):959-967. doi:10.21608/ASMJ.2020.148953.
11. Shafi AMA, Abuelgasim E, Abuelgasim B, Iddawela S, Harky A. Sternal closure with single compared with double or figure of 8 wires in obese patients following cardiac surgery: a systematic review and meta-analysis. J Card Surg. 2021;36(3):1072-1082. doi:10.1111/jocs.15339.
12. King M, Stambulic T, Hassan SMA, Norman PA, Derry K, Payne DM, et al. Median sternotomy pain after cardiac surgery: to block, or not? A systematic review and meta-analysis. J Card Surg. 2022;37(11):3729-3742. doi:10.1111/jocs.16882.
13. Yu J, Wei L, Li P, Zhang S. Effectiveness of early mobility interventions for the management of cardiac surgery patients: a meta-analysis. J Perianesth Nurs. 2026;41(3):614-623.e2. doi:10.1016/j.jopan.2025.08.010.
14. Wilson APR, Weavill C, Burridge J, Kelsey MC. The use of the wound scoring method 'ASEPSIS' in postoperative wound surveillance. J Hosp Infect. 1990;16(4):297-309. doi:10.1016/0195-6701(90)90002-6.
15. El-Ansary D, Waddington G, Denehy L, McManus M, Fuller L, Katijjahbe MA, et al. Physical assessment of sternal stability following a median sternotomy for cardiac surgery: validity and reliability of the Sternal Instability Scale (SIS). Int J Phys Ther Rehabil. 2018;4:140. doi:10.15344/2455-7498/2018/140.
16. Stone SP, Ali B, Auberleek I, Thompsell A, Young A. The Barthel Index in clinical practice: use on a rehabilitation ward for elderly people. J R Coll Physicians Lond. 1994;28(5):419-423.
17. Chen D, Zhang J, Wang Y, Jiang W, Xu Y, Xiong C, et al. Risk factors for sternal wound infection after open-heart operations: a systematic review and meta-analysis. Int Wound J. 2024;21(3):e14457. doi:10.1111/iwj.14457.
18. Gundestrup L, Florczak CK, Riber LPS. Factors associated with deep sternal wound infection after open-heart surgery in a Danish registry. Am Heart J Plus. 2023;31:100307. doi:10.1016/j.ahjo.2023.100307.
19. Maessen T, Korir N, Van de Velde M, Kennes J, Pogatzki-Zahn E, Joshi GP, et al. Pain management after cardiac surgery via median sternotomy: a systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol. 2023;40(10):758-768. doi:10.1097/EJA.0000000000001881.
20. Beyazal OF, Yanartas M. Which sternal closure technique is more beneficial in cardiac surgery: simple wire, figure-of-8, or their combination? Braz J Cardiovasc Surg. 2025;40(6):e20250011. doi:10.21470/1678-9741-2025-0011.