Sternal Zipfix System
Fig 1a-b: Sternal Zipfix System. The sternal zipfix system primarily consists of polyetheretherketone (PEEK), biocompatible implants, which are similar to cable ties, and an application instrument. The purpose of this system is to achieve sternal closure following sternotomy by stabilizing the sternum and promoting fusion.
The implant itself comprises a removable stainless steel needle for peristernal application, the body with a ratchet mechanism, and a flat locking head. The application instrument is used to tension the implant, without overtensioning it, and also to cut it.
Case 1: A 66-year-old man with a history of chronic obstructive disease, obesity (BMI of 32.8), and transient ischemic attack was scheduled for a coronary artery bypass operation for stable angina.
The patients angiogram showed three-vessel coronary disease with good left ventricular function and an echocardiogram sinus rhythm.
The hybrid sternal closure technique with stainless steel wires and sternal Zipfix has been used in the authors' institution in 50 patients without any instance of sternal instability or dehiscence.
Case provided by Ted Elenbaas and Sander Wolters, Eindhoven, The Netherlands
Fig 2a-b: Preclosure. The patient underwent coronary artery bypass surgery with two distal grafts, left internal mammary artery to the left anterior descending coronary artery, and a saphenous graft from the aorta to the right descending posterior coronary artery. The branches of the circumflex artery were too small and calcified to be bypassed (a). Final closure. The sternal closure was performed with three stainless steel wires in the manubrium, four sternal zipfix on the sternal bodies and two wires distally in the xiphoid region (b) 
Fig 3: The postoperative procedure was uneventful. The patient was extubated after 3 hours and transferred to the normal ward after 6 hours. There were no complications and no complaints of sternal pain or instability, and the patient was discharged after 6 days. 
Fig 4: Although the sternal zipfix cannot be detected with normal x-ray, the implants can be viewed with a CT scan and digital imaging techniques. The patient underwent a CT scan on the third postoperative day to evaluate the sternal closure. The CT scan showed a perfect alignment of the sternal halves. Postoperatively Case 2: A 55-year-old woman, who previously underwent ventricular septal defect closure at 5 and aortic valve reconstruction at 31, required aortic valve replacement due to symptomatic aortic valve insufficiency.
The patient was morbidly obese with a BMI of 45. Due to the high risk for sternal instability and/or deep sternal wound infection, closure was performed using the sternal zipfix system. The zipfix provides quick and reliable stable fixation of the sternum even in patients that are at a higher risk to develop a sternal instability or a deep sternal wound infection.
The postoperative course was uneventful and the patient was discharged on postoperative day 7 with no signs of sternal instability or wound healing problems. At 18 months follow-up the wound had healed completely and the sternum was stable, with no signs of infection.
Case provided by Roman Gottardi, Salzburg, Austria
Fig 5a-b: After systemic heparinization was reversed with protamine and hemostasis was achieved, the first to fifth intercostal spaces were dissected with minimal mobilization of the pectoral muscle allowing passage of the Zipfix 
Fig 6: Then five zipfix implants were passed peristernally through the intercostal spaces with special attention to avoid injury to the internal mammary arteries 
Fig 7a-b: The needles were cut and the sternal halves approximated gradually by tightening all Zipfix manually 
Fig 8a-d: When good approximation was achieved the Zipfix was finally tightened and cut using the application instrument Median Sternotomy Closure
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