Although alternative methods such as metal plates have been tested, wire cerclage remains the standard technique for closing a sternotomy after cardiac surgery. However, there is no established consensus on the optimal wire configuration, and practice is largely driven by institutional habits or individual surgeon preference. The reported incidence of wire fracture in the literature is around 2-3%, although the timing of fracture and its potential clinical implications are not well defined.
The investigators collected their data by analyzing all angiograms performed from January 2020 to May 2025 in which the left internal mammary artery had been cannulated to assess graft patency. This allowed them to identify patients who had previously undergone cardiac surgery. Among these cases, they selected those who had undergone full median sternotomy followed by closure with at least two wires.
The data were analyzed according to three categories: 1. Wire configuration, classified as simple interrupted wires, multitwist wires, figure-of-8 wires, and Robicsek weave closure. 2. Wire location within the sternum, distinguishing between the manubrium, upper sternal body, and lower sternal body. 3. Type of fracture, analyzing both the location of the break within the wire —knot, bend, middle portion, or exploded fracture— and the number of breakage points per wire. The variables included in the final logistic regression model to assess potential risk factors associated with fracture were age at the time of surgery, sex, BMI, and the time interval between surgery and angiography. Comorbidities of the patients included in the study were not collected.
A total of 639 patients were included, of whom 174 (27.2%) had at least one fractured wire. Overall, 4670 wires were assessed, of which 271 (5.8%) were fractured. Among patients with fractured wires, higher BMI, greater body surface area, male sex, and younger age at the time of surgery were identified as risk factors for fracture in the multivariable analysis, whereas older age at the time of surgery was considered protective. Most fractured wires (64.9%) had a single breakage point, with no differences in multivariable analysis between patients with single or multiple fractures. A higher number of multiple fractures was observed only as the time from surgery to angiography increased, which the authors relate to cumulative stress and shear forces acting on the wire over time. In fact, they estimate that the odds of observing a fractured wire increase by a factor of 1.03 for each additional year between surgery and angiography. However, because there is no zero-risk period for fracture in the immediate postoperative phase, they suggest that intraoperative factors may also influence wire failure.
Regarding wire configuration, multitwist wires had the lowest fracture rate, at 1.7%, followed by simple interrupted wires (5.8%) and figure-of-8 wires (8.6%). However, this pattern was not the same when stratified by sex: women had a significantly lower fracture rate with figure-of-8 wires, whereas men showed similar fracture rates across all configurations.
No significant differences were found in wire location between the two patient cohorts, with or without fractures. Among those with fractures, the most frequent locations were the sternal endpoints, with 17.2% in the most distal wire and 7.4% in the most proximal wire. Once again, older age at the time of surgery was a protective factor against wire fracture according to sternal position. The most frequent breakage site was the area where the wire bent or turned around the sternum, followed by the knot.
In summary, the authors conclude that fractures are less frequent with multitwist wire configurations and more frequent with figure-of-8 configurations. They are also more common at sternal endpoints and at sites where the wire bends around the sternum. These findings may help surgeons reconsider which closure strategy could be safer.
COMMENTARY:
After reading this study, one could initially draw the rather simplistic conclusion that, given that the effort required is the same, sternal closure with multitwist wires may be preferable, particularly at the sternal endpoints. However, although these are essentially the main findings, in my opinion the study has several limitations, some of which are acknowledged by the authors themselves. First, this is a single-center study, involving one type of wire and probably a relatively consistent sternal closure technique among the surgical team, which limits extrapolation to other settings. However, I believe the main limitation is that patient comorbidities were not analyzed. Therefore, the study does not account for whether patients were, for example, chronic coughers, had chronic pulmonary disease, were receiving long-term corticosteroid therapy that could predispose to sternal fractures and greater wire mobility, or had experienced postoperative disorientation or delirium. Nor does it consider the duration of postoperative intubation, falls, lack of adherence to poststernotomy care recommendations, or protective measures such as chest binders.
It is also unclear whether the presence of fractured wires is associated with meaningful clinical consequences. Although in a proportion of patients this may be related to chronic sternal discomfort, this association was not analyzed. In fact, the number of fractures increased as the time interval between surgery and angiography became longer, and it is very likely that a wire fracture occurring several years after sternal closure has no real clinical relevance. Among patients who had undergone more than one postoperative angiogram, only the wire images from the most recent angiogram were analyzed, which, in my opinion, missed the opportunity to define the timing of fracture more accurately. A more interesting approach might be a study using plain chest radiography to assess the presence of wire fractures during the first 24-48 months after surgery, which is the period of complete sternal healing, and to analyze whether wire fractures during that interval carry greater clinical implications.
Finally, the most appropriate management once a wire fracture is diagnosed also remains to be determined. Although the authors refer to some cases of complications due to wire migration causing cardiac or pulmonary laceration or tamponade, these are anecdotal cases. For that reason, the most logical approach is probably conservative management with simple surveillance once the fracture has been identified.
Nevertheless, given such specific findings, particularly the lower fracture rate with multitwist wires at the sternal endpoints, it would not be unreasonable to consider adopting these measures during sternal closure, as they do not require greater effort and may help reduce wire fractures, thereby potentially decreasing the complications that could arise from their presence.
REFERENCE:
Stoklosa K, Munteanu D, Lachapelle K, Spaziano M, Shum-Tim D, de Varennes B, et al. Fractured Sternal Wires Post Coronary Surgery: A Cross-Sectional Study Examining Wire Configurations, Sternal Locations, and Breakage Sites. Ann Thorac Surg. 2026 Feb 26:S0003-4975(26)00146-3. doi: 10.1016/j.athoracsur.2026.02.010.
