Modified Mini-Robicsek with Titanium Plate Fixation: A Novel Multidirectional Technique for Transverse Sternal Malunions

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Introduction: Sternal fractures are rare and successfully managed conservatively in most cases. Failure of conservative management is very rare but can result in a painful and disabling malunion. Treatment of this condition presents several difficulties and challenges. We present our novel multidirectional stabilization technique for the surgical repair of chronic symptomatic transverse sternal malunions, combining a limited modified mini-Robicsek and internal fixation with titanium plates. Methods: Four patients with simple and one patient with complex post-traumatic transverse sternal malunion were treated with this technique. All patients had at least one risk factor for impaired bone healing. Following exposure of the malunion, two transverse osteotomies were performed to fully mobilize the fractured edges and remove the fibrotic tissue. Sternal margins were refashioned to allow apposition of viable bone. A modified mini-Robicsek was constructed by placing two vertical and two horizontal wires and one or two vertical titanium plates ZIMMER BIOMET® were fashioned over the fracture and fixed with bicortical screws. In the simple cases, the minimal residual gap was filled with Cerament® bone void filler. In the complex case (4x2 cm sternal body defect post-osteomyelitis), the gap was filled with autologous bone graft from the iliac crest. Results: Mean operative time was 121 minutes (range 80 min to 180 min) and mean blood loss was 142 mL (range 10 mL to 200 mL). The mean length of stay was 5.6 days (2 to 11 days), and only one patient developed a postoperative complication (chest infection). At 6 months follow-up, there was clinical and radiological confirmation of successful repair in all cases, with a mean pain score decreasing from 7.4 to 0.8. Conclusion: This novel technique, combining 2 existing techniques, contrasts both vertical and horizontal forces, thus providing multi-directional stability of the transverse sternal malunion with auspicious results. If confirmed in larger studies, it may have the potential to become a new standard.

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