Sternal closure after median sternotomy has remained largely unchanged for decades, despite its central role in patient recovery and in preventing serious complications such as dehiscence and mediastinitis. Steel wire cerclage remains the most widely used technique worldwide, mainly because of its simplicity, availability, and familiarity. However, recent biomechanical studies have highlighted its limitations when exposed to distraction, torsional, and shear forces, which are common during coughing, early mobilization, or mechanical ventilation.

The article “Taken for Granted: An Analysis of Sternal Closure Techniques,” by Chopko, Khan, and Stulak, critically reviews the available evidence on the different methods of sternal closure, comparing their biomechanical performance, clinical applicability, and impact on postoperative outcomes. The authors emphasize that, although wire cerclage remains the standard, alternative strategies are available that provide greater stability, including steel bands, rigid fixation systems, and advanced wire configurations.

Steel wire cerclage remains, by a wide margin, the most commonly used technique. However, contemporary literature indicates that its biomechanical resistance is inferior to that of other systems.

Comparative studies show that rigid fixation systems, including plates and screws, provide superior resistance in nearly all modes of sternal deformation. Even so, their clinical adoption remains limited, partly because of cost, the need for specific training, and the perception that they should be reserved for high-risk patients.

The currently available clinical evidence is still insufficient to establish an alternative standard. Most studies are retrospective, include small sample sizes, and apply variable selection criteria. In addition, the choice of technique depends heavily on surgeon experience, resource availability, and patient anatomy. Even so, the literature consistently identifies closure stability as a key determinant of recovery and prevention of major complications.

Although wire cerclage remains the predominant technique, there is a clear need for prospective comparative studies to define which patients truly benefit from advanced closure techniques or rigid fixation.

COMMENTARY:

For years, sternal closure has been treated as an almost automatic step in cardiac surgery, regarded more as a routine technical detail than as a critical component of the operation. Clinical experience and biomechanical evidence, however, point in the same direction: sternal stability is essential for safe recovery and for preventing complications that may seriously compromise postoperative course.

The continued predominance of wire cerclage partly reflects surgical inertia and the need for rapid, reliable solutions in an environment where time and simplicity matter. Still, current data suggest that more stable alternatives do exist and may benefit selected patient groups, particularly those with risk factors such as osteoporosis, obesity, COPD, or redo surgery.

The incorporation of newer closure strategies requires training and gradual adaptation in everyday practice. Using modified wire configurations or rigid fixation systems does not mean abandoning conventional cerclage but rather expanding the range of options available to select the most appropriate closure for each patient. Biomechanical data support these alternatives, but robust clinical studies are still needed to confirm their value in real-world practice.

The question raised by Chopko et al. is straightforward: to what extent do we continue using conventional cerclage out of habit rather than evidence? In a setting where cardiac surgery is moving toward less invasive approaches and greater personalization, it seems reasonable to reassess sternal closure as well. Although it is a routine step, it has a direct effect on recovery and quality of life. In cardiac surgery, even seemingly routine steps deserve ongoing critical reappraisal.

REFERENCE:

Chopko TC, Khan FW, Stulak JM. Taken for Granted: An Analysis of Sternal Closure Techniques. Ann Thorac Surg. 2026 Jan;121(1):53-64. doi: 10.1016/j.athoracsur.2025.07.055.