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Vasanthan V, Hassanabad AF, Kang S, Dundas J, Ramadan D, Holloway D, Adams C, Ahsan M, Fedak PWM. Novel hardening bone putty enhances sternal closure and accelerates postoperative recovery. J Thorac Cardiovasc Surg 2023; 166:e430-e443. [PMID: 36272766 DOI: 10.1016/j.jtcvs.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/02/2022] [Accepted: 09/10/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Regaining and maintaining sternal stability are key to recovery after cardiac surgery and resuming baseline quality of life. Montage (ABYRX) is a moldable, calcium phosphate-based putty that adheres to bleeding bone, hardens after application, and is resorbed and replaced with bone during the remodeling process. We evaluate the feasibility, safety, and efficacy of enhanced sternal closure with this novel putty to accelerate recovery in patients after sternotomy. METHODS A single-center, single-blinded, randomized controlled trial was performed (NCT03365843). Patients undergoing elective cardiac surgery via sternotomy received sternal closure with either Montage bone putty and wire cerclage (enhanced sternal closure; n = 33) or wire cerclage alone (control; n = 27). Standardized patient-reported outcomes assessed health-related quality of life (EQ-5D Index) and physical disability (Health Assessment Questionnaire). A Likert-type 11-point scale quantified pain. Spirometry assessed respiratory function. Patients reached 6-week follow-up, with 1-year follow-up for safety end points. RESULTS There were no device-related adverse events. Enhanced sternal closure improved physical functional recovery (reduced Healthcare Index and Quality) and quality of life (increased EQ-5D Index) at day 5/discharge, week 2, and week 4. Enhanced sternal closure reduced incisional pain while resting, breathing, sleeping, and walking at day 5/discharge. Enhanced sternal closure reduced chest wall and back pain at day 3 and day 5 discharge. A higher proportion of patients with enhanced sternal closure recovered to 60% of their baseline forced vital capacity by day 5/discharge. Enhanced sternal closure shortened hospital stay. CONCLUSIONS Enhanced sternal closure improves and accelerates postoperative recovery compared with conventional wire closure. Earlier discharge may provide substantial cost benefits for the healthcare system.
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Affiliation(s)
- Vishnu Vasanthan
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean Kang
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jameson Dundas
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darlene Ramadan
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel Holloway
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Corey Adams
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Muhammad Ahsan
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul W M Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Giardini M, Guenzi M, Arcolin I, Godi M, Pistono M, Caligari M. Comparison of Two Techniques Performing the Supine-to-Sitting Postural Change in Patients with Sternotomy. J Clin Med 2023; 12:4665. [PMID: 37510778 PMCID: PMC10380334 DOI: 10.3390/jcm12144665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with sternotomy are advised to follow sternal precautions to avoid the risk of sternal complications. However, there are no standard recommendations, in particular to perform the supine-to-sitting postural change, where sternal asymmetrical force may be applied. The aim of this study was to compare the rotational movement and the use of a tied rope (individual device for supine-to-sitting, "IDSS") to perform the supine-to-sitting postural change. A total of 92 patients (26% female) admitted to a rehabilitative post-surgery ward with sternotomy were assessed for sternal instability. Levels of pain and perceived effort during the two modalities of postural change and at rest were assessed. Patients reported higher values of pain and perceived effort (both p < 0.0005) during rotational movement with respect to the use of the IDSS. Moreover, patients with sternal instability (14%) and female patients with macromastia (25%) reported higher pain than those stable or without macromastia (both p < 0.05). No other risk factors were associated with pain. Thus, the IDSS seems to reduce the levels of pain and perceived effort during the supine-to-sitting postural change. Future studies with quantitative assessments are required to suggest the adoption of this technique, mostly in patients with high levels of pain or with sternal instability.
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Affiliation(s)
- Marica Giardini
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Marco Guenzi
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Cardiac Rehabilitation of Veruno Institute, 28103 Gattico-Veruno, Italy
| | - Ilaria Arcolin
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Marco Godi
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Massimo Pistono
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Cardiac Rehabilitation of Veruno Institute, 28103 Gattico-Veruno, Italy
| | - Marco Caligari
- Istituti Clinici Scientifici Maugeri IRCCS, Integrated Laboratory of Assistive Solutions and Translational Research (LISART), Scientific Institute of Pavia, 27100 Pavia, Italy
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Claessens J, Rottiers R, Vandenbrande J, Gruyters I, Yilmaz A, Kaya A, Stessel B. Quality of life in patients undergoing minimally invasive cardiac surgery: a systematic review. Indian J Thorac Cardiovasc Surg 2023; 39:367-380. [PMID: 37346428 PMCID: PMC10279589 DOI: 10.1007/s12055-023-01501-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 04/05/2023] Open
Abstract
Objective Minimally invasive procedures have been developed to reduce surgical trauma after cardiac surgery. Clinical recovery is the main focus of most research. Still, patient-centred outcomes, such as the quality of life, can provide a more comprehensive understanding of the impact of the surgery on the patient's life. This systematic review aims to deliver a detailed summary of all available research investigating the quality of recovery, assessed with quality of life instruments, in adults undergoing minimally invasive cardiac surgery. Methods All randomised trials, cohort studies, and cross-sectional studies assessing the quality of recovery in patients undergoing minimally invasive cardiac surgery compared to conventional cardiac surgery within the last 20 years were included, and a summary was prepared. Results The randomised trial observed an overall improved quality of life after both minimally invasive and conventional surgery. The quality of life improvement in the minimally invasive group showed a faster course and evolved to a higher level than the conventional surgery group. These findings align with the results of prospective cohort studies. In the cross-sectional studies, no significant difference in the quality of life was seen except for one that observed a significantly higher quality of life in the minimally invasive group. Conclusions This systematic review indicates that patients may benefit from minimally invasive and conventional cardiac surgery, but patients undergoing minimally invasive cardiac surgery may recover sooner and to a greater extent. However, no firm conclusion could be drawn due to the limited available studies. Therefore, randomised controlled trials are needed.
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Affiliation(s)
- Jade Claessens
- Department of Cardiothoracic Surgery, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, LCRC, UHasselt - Hasselt University, Martelarenlaan 45, 3500 Hasselt, Belgium
| | - Roxanne Rottiers
- Faculty of Medicine and Life Sciences, LCRC, UHasselt - Hasselt University, Martelarenlaan 45, 3500 Hasselt, Belgium
- Department of Anesthesiology and Perioperative Medicine, Ghent University, Corneel Heymanslaan 10, Ghent, Belgium
| | - Jeroen Vandenbrande
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
| | - Ine Gruyters
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
| | - Alaaddin Yilmaz
- Department of Cardiothoracic Surgery, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
| | - Abdullah Kaya
- Department of Cardiothoracic Surgery, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, LCRC, UHasselt - Hasselt University, Martelarenlaan 45, 3500 Hasselt, Belgium
| | - Björn Stessel
- Faculty of Medicine and Life Sciences, LCRC, UHasselt - Hasselt University, Martelarenlaan 45, 3500 Hasselt, Belgium
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
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Trunk stabilising exercises promote sternal stability in patients after median sternotomy for heart valve surgery: a randomised trial. J Physiother 2022; 68:197-202. [PMID: 35753968 DOI: 10.1016/j.jphys.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 10/27/2021] [Accepted: 06/06/2022] [Indexed: 11/22/2022] Open
Abstract
QUESTION What is the effect of trunk stabilising exercises on sternal stability in women who have undergone heart valve surgery via median sternotomy? DESIGN Randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. PARTICIPANTS Thirty-six women aged 40 to 50 years who had undergone heart valve surgery via median sternotomy 7 days before enrolment. INTERVENTION All participants in both groups received cardiac rehabilitation during hospitalisation and three times per week for 4 weeks after discharge. In addition, participants in the experimental group were prescribed a regimen of trunk stabilising exercises to be performed three times per week for 4 weeks. At each exercise session, each of 11 exercises were to be performed with five to ten repetitions. OUTCOME MEASURES The primary outcome was sternal separation (the distance between the two halves of the bisected sternum). The secondary outcome was the Sternal Instability Scale from 0 (no instability) to 3 (an unstable sternum with substantial movement or separation). Measures were taken before and after the 4-week intervention period. RESULTS After the 4-week intervention period, the experimental group had a greater decrease in sternal separation by 0.09 cm (95% CI 0.07 to 0.11). The experimental group was twice as likely to improve by at least one grade on the Sternal Instability Scale by 4 weeks (RR 2.00, 95% CI 1.07 to 3.75). The experimental group was almost three times as likely to have a clinically stable sternum (grade 0 on the Sternal Instability Scale) by 4 weeks (RR 2.75, 95% CI 1.07 to 7.04). CONCLUSION Trunk stabilising exercises were an effective and feasible method of promoting sternal stability in women who underwent heart valve surgery via median sternotomy. TRIAL REGISTRATION NCT04632914.
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Pengelly J, Boggett S, Bryant A, Royse C, Royse A, Williams G, El-Ansary D. SAfety and Feasibility of EArly Resistance Training After Median Sternotomy: The SAFE-ARMS Study. Phys Ther 2022; 102:6585156. [PMID: 35551413 PMCID: PMC9351378 DOI: 10.1093/ptj/pzac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/22/2021] [Accepted: 02/17/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the safety and feasibility of subacute upper limb resistance exercise on sternal micromotion and pain and the reliability of sternal ultrasound assessment following cardiac surgery via median sternotomy. METHODS This experimental study used a pretest-posttest design to investigate the effects of upper limb resistance exercise on the sternum in patients following their first cardiac surgery via median sternotomy. Six bilateral upper limb machine-based exercises were commenced at a base resistance of 20 lb (9 kg) and progressed for each participant. Sternal micromotion was assessed using ultrasound at the mid and lower sternum at 2, 8, and 14 weeks postsurgery. Intrarater and interrater reliability was calculated using intraclass correlation coefficients (ICCs). Participant-reported pain was recorded at rest and with each exercise using a visual analogue scale. RESULTS Sixteen adults (n = 15 males; 71.3 [SD = 6.2] years of age) consented to participate. Twelve participants completed the study, 2 withdrew prior to the 8-week assessment, and 2 assessments were not completed at 14 weeks due to assessor unavailability. The highest median micromotion at the sternal edges was observed during the bicep curl (median = 1.33 mm; range = -0.8 to 2.0 mm) in the lateral direction and the shoulder pulldown (median = 0.65 mm; range = -0.8 to 1.6 mm) in the anterior-posterior direction. Furthermore, participants reported no increase in pain when performing any of the 6 upper limb exercises. Interrater reliability was moderate to good for both lateral-posterior (ICC = 0.73; 95% CI = 0.58 to 0.83) and anterior-posterior micromotion (ICC = 0.83; 95% CI = 0.73 to 0.89) of the sternal edges. CONCLUSION Bilateral upper limb resistance exercises performed on cam-based machines do not result in sternal micromotion exceeding 2.0 mm or an increase in participant-reported pain. IMPACT Upper limb resistance training commenced as early as 2 weeks following cardiac surgery via median sternotomy and performed within the safe limits of pain and sternal micromotion appears to be safe and may accelerate postoperative recovery rather than muscular deconditioning.
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Affiliation(s)
| | - Stuart Boggett
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
| | - Adam Bryant
- Department of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia
| | - Colin Royse
- Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Victoria, Australia,Department of Surgery, University of Melbourne, Parkville, Victoria, Australia,Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia,Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alistair Royse
- Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Victoria, Australia,Department of Surgery, University of Melbourne, Parkville, Victoria, Australia,Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Gavin Williams
- Department of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia
| | - Doa El-Ansary
- Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Victoria, Australia,Department of Surgery, University of Melbourne, Parkville, Victoria, Australia,Clinical Research Institute, Westmead Private Hospital, Westmead, New South Wales, Australia
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Selten K, Schnoering H, Zayat R, Aljalloud A, Moza A, Autschbach R, Tewarie L. Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset. Ann Thorac Cardiovasc Surg 2021; 27:25-31. [PMID: 32611929 PMCID: PMC8043031 DOI: 10.5761/atcs.oa.19-00293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients. Methods: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks. Results: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006). Conclusion: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.
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Affiliation(s)
- Koen Selten
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Heike Schnoering
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Ali Aljalloud
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Ajay Moza
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Lachmandath Tewarie
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
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Katijjahbe MA, Royse C, Granger C, Denehy L, Md Ali NA, Abdul Rahman MR, King-Shier K, Royse A, El-Ansary D. Location and Patterns of Persistent Pain Following Cardiac Surgery. Heart Lung Circ 2021; 30:1232-1243. [PMID: 33608196 DOI: 10.1016/j.hlc.2020.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/11/2020] [Accepted: 12/19/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the specific clinical features of pain following cardiac surgery and evaluate the information derived from different pain measurement tools used to quantify and describe pain in this population. METHODS A prospective observational study was undertaken at two tertiary care hospitals in Australia. Seventy-two (72) adults (mean age, 63±11 years) were included following cardiac surgery via a median sternotomy. Participants completed the Patient Identified Cardiac Pain using numeric and visual prompts (PICP), the McGill Pain Questionnaire-Short Form version 2 (MPQ-2) and the Medical Outcome Study 36-item version 2 (SF-36v2) Bodily Pain domain (BP), which were administered prior to hospital discharge, 4 weeks and 3 months postoperatively. RESULTS Participants experienced a high incidence of mild (n=45, 63%) to moderate (n=22, 31%) pain prior to discharge, which reduced at 4 weeks postoperatively: mild (n=28, 41%) and moderate (n=5, 7%) pain; at 3 months participants reported mild (n=14, 20%) and moderate (n=2, 3%) pain. The most frequent location of pain was the anterior chest wall, consistent with the location of the surgical incision and graft harvest. Most participants equated "pressure/weight" to "aching" or a "heaviness" in the chest region (based on descriptor of pain in the PICP) and the pain topography was persistent at 4 weeks and 3 months postoperatively. Each pain measurement tool provided different information on pain location, severity and description, with significant change (p<0.005) over time. CONCLUSION Mild-to-moderate pain was frequent after sternotomy, improved over time and was mostly located over the incision and mammary (internal thoracic) artery harvest site. Persistent pain at 3 months remained a significant problem in the community within this surgical population.
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Affiliation(s)
- Mohd Ali Katijjahbe
- Department of Physiotherapy, Hospital Canselor Tunku Mukhriz, University, Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia; Department of Nursing and Allied Health, School of Health Sciences, Swinburne University of Technology, Hawthorn, Australia.
| | - Colin Royse
- Department of Nursing and Allied Health, School of Health Sciences, Swinburne University of Technology, Hawthorn, Australia; Department of Surgery, Melbourne Medical School, The University of Melbourne, Parkville, Australia; Australian Director, Outcomes Research Consortium, Cleveland Clinic, Cleveland, USA
| | - Catherine Granger
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia; Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, Australia
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia
| | - Nur Ayub Md Ali
- Cardiothoracic Surgery, Heart and Lung Centre, UKM Medical Centre, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mohd Ramzisham Abdul Rahman
- Cardiothoracic Surgery, Heart and Lung Centre, UKM Medical Centre, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Kathryn King-Shier
- Faculty of Nursing and Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Alistair Royse
- Department of Nursing and Allied Health, School of Health Sciences, Swinburne University of Technology, Hawthorn, Australia; Department of Surgery, Melbourne Medical School, The University of Melbourne, Parkville, Australia
| | - Doa El-Ansary
- Department of Nursing and Allied Health, School of Health Sciences, Swinburne University of Technology, Hawthorn, Australia; Department of Surgery, Melbourne Medical School, The University of Melbourne, Parkville, Australia; Clinical Research Institute, Westmead Private Hospital, Westmead, Australia
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8
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Pengelly JMS, Royse AG, Bryant AL, Williams GP, Tivendale LJ, Dettmann TJ, Canty DJ, Royse CF, El-Ansary DA. Effects of Supervised Early Resistance Training versus standard care on cognitive recovery following cardiac surgery via median sternotomy (the SEcReT study): protocol for a randomised controlled pilot study. Trials 2020; 21:649. [PMID: 32669111 PMCID: PMC7362413 DOI: 10.1186/s13063-020-04558-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 06/26/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Mild cognitive impairment is considered a precursor to dementia and significantly impacts upon quality of life. The prevalence of mild cognitive impairment is higher in the post-surgical cardiac population than in the general population, with older age and comorbidities further increasing the risk of cognitive decline. Exercise improves neurogenesis, synaptic plasticity and inflammatory and neurotrophic factor pathways, which may help to augment the effects of cognitive decline. However, the effects of resistance training on cognitive, functional and overall patient-reported recovery have not been investigated in the surgical cardiac population. This study aims to determine the effect of early moderate-intensity resistance training, compared to standard care, on cognitive recovery following cardiac surgery via a median sternotomy. The safety, feasibility and effect on functional recovery will also be examined. Methods This study will be a prospective, pragmatic, pilot randomised controlled trial comparing a standard care group (low-intensity aerobic exercise) and a moderate-intensity resistance training group. Participants aged 18 years and older with coronary artery and/or valve disease requiring surgical intervention will be recruited pre-operatively and randomised 1:1 to either the resistance training or standard care group post-operatively. The primary outcome, cognitive function, will be assessed using the Alzheimer’s Disease Assessment Scale and cognitive subscale. Secondary measures include safety, feasibility, muscular strength, physical function, multiple-domain quality of recovery, dynamic balance and patient satisfaction. Assessments will be conducted at baseline (pre-operatively) and post-operatively at 2 weeks, 8 weeks, 14 weeks and 6 months. Discussion The results of this pilot study will be used to determine the feasibility of a future large-scale randomised controlled trial that promotes the integration of early resistance training into existing aerobic-based cardiac rehabilitation programs in Australia. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001430325p. Registered on 9 October 2017. Universal Trial Number (UTN): U1111-1203-2131.
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Affiliation(s)
- Jacqueline M S Pengelly
- Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Melbourne, Victoria, Australia.
| | - Alistair G Royse
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Adam L Bryant
- Department of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia
| | - Gavin P Williams
- Department of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia
| | - Lynda J Tivendale
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | | | - David J Canty
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia.,Department of Anaesthesia and Perioperative Medicine, Monash Health, Clayton, Victoria, Australia
| | - Colin F Royse
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Australian Director, Outcomes Research Consortium Cleveland Clinic, Cleveland, Ohio, USA
| | - Doa A El-Ansary
- Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Research Institute, Westmead Private Hospital, Westmead, Sydney, NSW, Australia
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9
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Royse AG, El-Ansary D, Hoang W, Lui E, McCusker M, Tivendale L, Yang Y, Canty DJ, Royse CF. A randomized trial comparing the effects of sternal band and plate fixation of the sternum with that of figure-of-8 wires on sternal edge motion and quality of recovery after cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:863-870. [DOI: 10.1093/icvts/ivaa040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/17/2020] [Accepted: 02/03/2020] [Indexed: 12/15/2022] Open
Abstract
Abstract
OBJECTIVES
We sought to compare the effects of conventional wire cerclage with that of the band and plate fixation of the sternum.
METHODS
A parallel randomized open-label trial with 1:1 allocation ratio compared healing after adult cardiac surgery using ‘figure-of-8’ stainless steel wire cerclage or a band and plate system (plates). The primary end point was maximal sternal edge displacement during active coughing of ≥2 mm in ≥2 of 4 sites measured with ultrasound by 2 assessors blinded to the other at 6 weeks postoperatively. Secondary end points at 12 weeks included ultrasound assessment, computed tomography (CT) scan and multidimensional assessment of quality of recovery using the Postoperative Quality of Recovery Scale.
RESULTS
Of 50 patients, 26 received plates and 24 wires. Two patients died and 1 withdrew consent leaving 25 plates and 22 wires for primary end point analysis. Operations included 37 coronary, 5 valve and 8 combined coronary and valve procedures. At 6 weeks, less sternal movement was observed in patients with plates than those with wires, 4% (1/25) vs 32% (7/22), P = 0.018. Agreement between observers was high, kappa = 0.850. At 12 weeks, less ultrasound motion was seen in patients with plates, 0% (0/23) than those with wires, 25% (5/20), P = 0.014. Recovery from pain was higher for patients with plates 92% (22/24) than those with wires 67% (14/21), P = 0.004. CT bone edge separation was less for plates 38% (9/24) than wires 71% (15/21), P = 0.036. CT mild bone synthesis or greater was similar between patients with plates 21% (5/24) and wires 14% (3/21), P = 0.71.
CONCLUSIONS
Patients receiving the band and plate system had significantly less sternal edge motion than those receiving wires, 6 and 12 weeks after cardiac surgery and experienced less pain.
Clinical trial registration
clinicaltrials.gov NCT03282578.
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Affiliation(s)
- Alistair G Royse
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Health Professions, Faculty of Art, Design and Health, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Doa El-Ansary
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Health Professions, Faculty of Art, Design and Health, Swinburne University of Technology, Melbourne, VIC, Australia
| | - William Hoang
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Elaine Lui
- Department of Radiology, The University of Melbourne, Parkville, VIC, Australia
| | - Mark McCusker
- Department of Radiology, The University of Melbourne, Parkville, VIC, Australia
| | - Lynda Tivendale
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Yang Yang
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Intensive Care, Western Hospital, Melbourne, VIC, Australia
| | - David J Canty
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Anaesthesia and Pain Management, Monash Medical Centre, Melbourne, VIC, Australia
| | - Colin F Royse
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Health Professions, Faculty of Art, Design and Health, Swinburne University of Technology, Melbourne, VIC, Australia
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Outcomes Research Consortium, The Cleveland Clinic, Cleveland, OH, USA
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10
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Nozawa E, Gonçalves CD, Almeida POD, Hajjar LA, Galas FRG, Feltrim MIZ. Infra-Abdominal Muscles Activation Brings Benefits to the Pulmonary Function of Patients with Sternal Instability after Cardiac Surgery. Braz J Cardiovasc Surg 2020; 35:41-49. [PMID: 32270959 PMCID: PMC7089742 DOI: 10.21470/1678-9741-2018-0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To compare physical therapy strategies involving abdominal muscle stabilization, with and without upper limb movement, in patients with sternal instability after heart surgery and during in-hospital care. Methods This prospective, longitudinal, randomized, and comparative clinical study included 20 patients, which were divided into two groups: ARM, the arm group (n=10), and LEG, the leg group (n=10). The study involved the evaluation of scores of visual analog scales for sternal instability, pain, discomfort, functional impairment, lung function, and maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) before and after the interventions. Two protocols consisting of abdominal exercises in both groups with upper limb movements (ARM) and just abdominal activation with leg movements (LEG) were used for three weeks. Results There were statistically significant (P≤0.01) improvements in pain, discomfort, and functional impairment scores, and in MIP (P=0.04) and MEP (P≤0.01) after intervention in both groups and just LEG showed improvement in forced vital capacity (P=0.043) and forced expiratory volume in one second (P=0.011). Conclusion Both strategies promoted improvement in pain, discomfort, and functional impairment scores and in the values of inspiratory and expiratory pressures. Perhaps they were influenced by the time and resolution of the infection process, although exercises with upper limb movements seem to be safe in this population. The activation of the infra-abdominal muscles through leg movements seems to bring more benefits to lung function.
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Affiliation(s)
- Emilia Nozawa
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Physiotherapy of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Cristiane Domingues Gonçalves
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Physiotherapy of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Patricia Oliva de Almeida
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Physiotherapy of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Ludhmila Abrahão Hajjar
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Critical Patients of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Filomena Regina Gomes Galas
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Anesthesia and Surgical Intensive Care of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Maria Ignêz Zanetti Feltrim
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Physiotherapy of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
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11
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El-Ansary D, LaPier TK, Adams J, Gach R, Triano S, Katijjahbe MA, Hirschhorn AD, Mungovan SF, Lotshaw A, Cahalin LP. An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy. Phys Ther 2019; 99:1587-1601. [PMID: 31504913 DOI: 10.1093/ptj/pzz126] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 03/07/2019] [Accepted: 04/30/2019] [Indexed: 02/07/2023]
Abstract
Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contribute to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8 weeks. This perspective paper proposes that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. A clinical paradigm shift is encouraged, one that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.
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Affiliation(s)
- Doa El-Ansary
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology, Melbourne, Victoria, Australia; Department of Surgery, School of Medicine, University of Melbourne, Melbourne, Australia; and Clinical Research Institute, Sydney, Australia. Address all correspondence to Associate Professor El-Ansary at:
| | - Tanya Kinney LaPier
- Department of Physical Therapy, Eastern Washington University, Spokane, Washington. Dr LaPier is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy
| | - Jenny Adams
- Baylor Institute for Rehabilitation, Baylor University Medical Center, Dallas, Texas
| | - Richard Gach
- Department of Rehabilitation Services, Memorial Regional Hospital, Hollywood, Florida
| | - Susan Triano
- Department of Rehabilitation Services, Memorial Regional Hospital, Hollywood, Florida
| | - Md Ali Katijjahbe
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology Department of Physiotherapy, Hospital Canselor Tuanku Muhriz, UKM Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Andrew D Hirschhorn
- MQ Health Physiotherapy and Department of Health Professions, Faculty of Medicine and Health, Macquarie University, Sydney, Australia
| | - Sean F Mungovan
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology, Clinical Research Institute and Westmead Private Physiotherapy Services, Westmead Private Hospital, Sydney, Australia
| | - Ana Lotshaw
- Baylor Institute for Rehabilitation, Baylor University Medical Center. Dr Lotshaw is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy
| | - Lawrence P Cahalin
- Department of Physical Therapy, Miller School of Medicine, University of Miami, Coral Gables, Florida
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12
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Resistance Training Following Median Sternotomy: A Systematic Review and Meta-Analysis. Heart Lung Circ 2019; 28:1549-1559. [DOI: 10.1016/j.hlc.2019.05.097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/10/2019] [Accepted: 05/03/2019] [Indexed: 12/17/2022]
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13
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Measurement of Adhesion of Sternal Wires to a Novel Bioactive Glass-Based Adhesive. J Funct Biomater 2019; 10:jfb10030037. [PMID: 31405006 PMCID: PMC6787671 DOI: 10.3390/jfb10030037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 07/29/2019] [Accepted: 08/05/2019] [Indexed: 11/17/2022] Open
Abstract
Stainless steel wires are the standard method for sternal closure because of their strength and rigidity, the simplicity of the process, and the short healing time that results from their application. Despite this, problems still exist with sternal stability due to micromotion between the two halves of the dissected and wired sternum. Recently, a novel glass-based adhesive was developed which, in cadaveric trials and in conjunction with wiring, was shown to restrict this micromotion. However, in order to avoid complications during resternotomy, the adhesive should adhere only to the bone and not the sternal wire. In this study, sternal wires were embedded in 8 mm discs manufactured from the novel glass-based adhesive and the constructs were then incubated at 37 °C for one, seven, and 30 days. The discs were manufactured in two different thicknesses: 2 and 3 mm. Wire pull-out tests were then performed on the constructs at three different strain rates (1, 0.1, and 0.01 mm/min). No statistically significant difference in pull-out force was found regardless of incubation time, loading rate, or construct thickness. The pull-out forces recorded were consistent with static friction between the wire and adhesive, rather than the adhesion between them. Scanning electron micrographs provided further proof of this. These results indicate that the novel adhesive may be suitable for sternal fixation without complicating a potential resternotomy.
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14
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Casha AR, Chircop K, Gauci M, Grima JN. Novel roles of vibration transmittance in fracture testing. J Cardiothorac Surg 2019; 14:53. [PMID: 30867001 PMCID: PMC6417125 DOI: 10.1186/s13019-019-0884-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/04/2019] [Indexed: 11/10/2022] Open
Abstract
This letter re-assesses a publication in the Journal of Cardiothoracic Surgery entitled 'Vibration transmittance measures sternotomy stability - a preliminary study in human cadavers.' The roles of ultrasound in testing for sternotomy stability and that of stress vibration transmittance in cases of fracture of the posterior table of the sternum or in hairline undisplaced fractures are examined in view of their differing sound wave frequency ranges.
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Affiliation(s)
- Aaron R Casha
- Department of Cardiothoracic Surgery, Mater Dei Hospital, Msida, Malta. .,Faculty of Medicine, University of Malta, Msida, Malta.
| | - Kieran Chircop
- Department of Medical Imaging, Mater Dei Hospital, Msida, Malta
| | - Marilyn Gauci
- Faculty of Medicine, University of Malta, Msida, Malta
| | - Joseph N Grima
- Metamaterials Unit, Faculty of Science, University of Malta, Msida, Malta
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15
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Hautalahti J, Joutsen A, Goebeler S, Luukkaala T, Khan J, Hyttinen J, Laurikka J. Vibration transmittance measures sternotomy stability - a preliminary study in human cadavers. J Cardiothorac Surg 2019; 14:2. [PMID: 30616661 PMCID: PMC6323770 DOI: 10.1186/s13019-018-0823-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stability is essential for the normal healing of a sternotomy. Mechanical vibration transmittance may provide a new means of early detection of diastasis in the sternotomy and thus enable the prevention of further complications. We sought to confirm that vibration transmittance detects sternal diastasis in human tissue. METHODS Ten adult human cadavers (8 males and 2 females) were used for sternal assessments with a device constructed in-house to measure the transmittance of a vibration stimulus across the median sternotomy at the second, third, and fourth costal cartilage. Intact bone was compared to two fixed bone junctions, namely a stable wire fixation and an unstable wire fixation with a 10 mm wide diastasis mimicking a widely rupturing sternotomy. A generalized Linear Mixed Model with the lme function was used to determine the ability of the vibration transmittance device to differentiate mechanical settings in the sternotomy. RESULTS The transmitted vibration power was statistically significantly different between the intact chest and stable sternotomy closure, stable and unstable closure, as well as intact and unstable closure (t-values and p-values respectively: t = 6.87, p < 0.001; t = 7.41, p < 0.001; t = 14.3, p < 0.001). The decrease of vibration transmittance from intact to stable at all tested costal levels was 78%, from stable to unstable 58%, and from intact to unstable 91%. The vibration transmittance power was not statistically significantly different between the three tested costal levels (level 3 vs. level 2; level 4 vs. level 2; level 4 vs. level 3; t-values and p-values respectively t = - 0.36, p = 0.723; t = 0.35, p = 0.728; t = 0.71, p = 0.484). CONCLUSIONS Vibration transmittance analysis differentiates the intact sternum, wire fixation with exact apposition, and wire fixation with a gap. The gap detection capability is not dependent on the tested costal level. The method may prove useful in the early detection of sternal instability and warrants further exploration.
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Affiliation(s)
- Juha Hautalahti
- Department of Cardiothoracic Surgery, Tampere Heart Hospital Co., Ensitie 4, FI-33520, Tampere, Finland. .,Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, FI-33520, Tampere, Finland.
| | - Atte Joutsen
- Department of Cardiothoracic Surgery, Tampere Heart Hospital Co., Ensitie 4, FI-33520, Tampere, Finland.,BioMediTech Institute and Faculty of Biomedical Sciences and Engineering, Tampere University of Technology, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
| | - Sirkka Goebeler
- Forensic Medicine, National Institute for Health and Welfare, Biokatu 16, O-building, FI-33520, Tampere, Finland
| | - Tiina Luukkaala
- Science Center, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland.,Health Sciences, Faculty of Social Sciences, University of Tampere, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
| | - Jahangir Khan
- Department of Cardiothoracic Surgery, Tampere Heart Hospital Co., Ensitie 4, FI-33520, Tampere, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
| | - Jari Hyttinen
- BioMediTech Institute and Faculty of Biomedical Sciences and Engineering, Tampere University of Technology, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
| | - Jari Laurikka
- Department of Cardiothoracic Surgery, Tampere Heart Hospital Co., Ensitie 4, FI-33520, Tampere, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
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16
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Helmy ZM, Mehani SHM, El-Refaey BH, Al-Salam EHA, Felaya ESEES. Low-level laser therapy versus trunk stabilization exercises on sternotomy healing after coronary artery bypass grafting: a randomized clinical trial. Lasers Med Sci 2018; 34:1115-1124. [DOI: 10.1007/s10103-018-02701-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/30/2018] [Indexed: 01/01/2023]
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17
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Marasco SF, Fuller L, Zimmet A, McGiffin D. To zip or wire: An ongoing debate. J Thorac Cardiovasc Surg 2018; 156:1612-1613. [PMID: 30248799 DOI: 10.1016/j.jtcvs.2018.05.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Silvana F Marasco
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Louise Fuller
- Physiotherapy Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adam Zimmet
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David McGiffin
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
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18
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Allen KB, Icke KJ, Thourani VH, Naka Y, Grubb KJ, Grehan J, Patel N, Guy TS, Landolfo K, Gerdisch M, Bonnell M. Sternotomy closure using rigid plate fixation: a paradigm shift from wire cerclage. Ann Cardiothorac Surg 2018; 7:611-620. [PMID: 30505745 DOI: 10.21037/acs.2018.06.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Rigid plate fixation (RPF) is the cornerstone in managing fractures and osteotomies except for sternotomy, where most cardiac surgeons continue to use wire cerclage (WC). Results of a multicenter randomized trial evaluating sternal healing, sternal complications, patient reported outcome measures (PROMs), and costs after sternotomy closure with RPF or WC are summarized here. Methods Twelve US centers randomized 236 patients to either RPF (n=116) or WC (n=120). The primary endpoint, sternal healing at 6 months, was evaluated by a core laboratory using computed tomography and a validated 6-point scale (greater scores represent greater healing). Secondary endpoints assessed through 6 months included sternal complications and PROMs. Costs from the time of sternal closure through 90 days and 6 months were analyzed by a health economic core laboratory. Results RPF compared to WC resulted in better sternal healing scores at 3 (2.6±1.1 vs. 1.8±1.0; P<0.0001) and 6 months (3.8±1.0 vs. 3.3±1.1; P=0.0007) and higher sternal union rates at 3 [41% (42/103) vs. 16% (16/102); P<0.0001] and 6 months [80% (81/101) vs. 67% (67/100); P=0.03]. There were fewer sternal complications with RPF through 6 months [0% (0/116) vs. 5% (6/120); P=0.03] and a trend towards fewer sternal wound infections [0% (0/116) vs. 4.2% (5/120); P=0.06]. All PROMs including sternal pain, upper extremity function (UEF), and quality-of-life scores were numerically better in RPF patients compared to WC patients at all follow-up time points. Although RPF was associated with a trend toward higher index hospitalization costs, a trend towards lower follow-up costs resulted in total costs that were $1,888 less at 90 days in RPF patients compared to WC patients (95% CI: -$8,889 to $4,273; P=0.52) and $1,646 less at 6 months (95% CI: -$9,127 to $4,706; P=0.61). Conclusions Sternotomy closure with RPF resulted in significantly better sternal healing, fewer sternal complications, improved PROMs and was cost neutral through 90 days and 6 months compared to WC.
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Affiliation(s)
- Keith B Allen
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | | | | | | | | | | | | | | | - Marc Gerdisch
- Franciscan St. Francis Health, Indianapolis, IN, USA
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19
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Balachandran S, Denehy L, Lee A, Royse C, Royse A, El-Ansary D. Motion at the Sternal Edges During Upper Limb and Trunk Tasks In-Vivo as Measured by Real-Time Ultrasound Following Cardiac Surgery: A Three-Month Prospective, Observational Study. Heart Lung Circ 2018; 28:1283-1291. [PMID: 30194001 DOI: 10.1016/j.hlc.2018.05.195] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 05/02/2018] [Accepted: 05/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite a paucity of evidence, patients following cardiac surgery via median sternotomy are routinely prescribed sternal precautions that restrict upper limb and trunk movements, with the rationale of reducing postoperative sternal complications such as sternal wound dehiscence, instability, infection and/or pain. The primary aim of this study was to measure motion at the sternal edges during dynamic upper limb and trunk tasks to better inform future sternal precautions and optimise postoperative recovery. Motion at the sternal edges was measured using ultrasound, which has been demonstrated to be a clinically valid and reliable measure in patients following cardiac surgery. METHODS Seventy-five (75) patients following cardiac surgery via median sternotomy with conventional stainless steel wire closure were recruited. Motion at the sternal edges in the lateral (coronal plane) and anterior-posterior (sagittal plane) directions was measured at the level of the fourth intercostal space (mid-sternum) using ultrasound. Ultrasound measures were taken at rest and during five dynamic upper limb and trunk tasks (deep inspiration, cough, unilateral and bilateral upper limb elevation and sit to stand), over the first 3 postoperative months (3 to 7 days, 6 weeks and 3 months postoperatively). Sternal pain, functional status and sternal healing were also observed over the same postoperative period. RESULTS The magnitude of overlap of the sternal edges in the lateral direction, and separation of the sternal edges in the anterior-posterior direction, both significantly decreased by 0.01cm, over the first 3 postoperative months (p<0.01). Coughing, however, produced a significant increase in separation of the sternal edges in the lateral direction (0.01-0.02cm) and pain (12-63%), compared to rest and all other tasks, at each postoperative time point (p<0.01). Additionally, there was a significant decrease in sternal pain (81%) and increase in postoperative function (79%) over the same postoperative period (p<0.01). At 3 months postoperatively, five (7%) participants demonstrated radiological sternal union and one (1%) participant was diagnosed with clinical sternal instability. CONCLUSIONS A small magnitude of multi-planar motion at the sternal edges, at the mid-sternum, was demonstrated during dynamic upper limb and trunk tasks in a cohort of cardiac surgery patients post-sternotomy, over the first 3 postoperative months. Future research investigating motion at different levels of the sternum, with varying methods of sternal closure, and over a longer postoperative period is warranted to better inform sternal precautions and optimise postoperative recovery.
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Affiliation(s)
- Sulakshana Balachandran
- Physiotherapy Department, The University of Melbourne, Melbourne, Vic, Australia; Physiotherapy Department, Greenslopes Private Hospital, Brisbane, Qld, Australia.
| | - Linda Denehy
- Physiotherapy Department, The University of Melbourne, Melbourne, Vic, Australia
| | - Annemarie Lee
- Physiotherapy Department, Monash University, Melbourne, Vic, Australia
| | - Colin Royse
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Alistair Royse
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Doa El-Ansary
- Physiotherapy Department, The University of Melbourne, Melbourne, Vic, Australia; Department of Surgery, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Health Professions, Swinburne University, Melbourne, Vic, Australia; Clinical Research Institute, Westmead Private Hospital, Sydney, NSW, Australia.
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20
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Rigid Plate Fixation Versus Wire Cerclage: Patient-Reported and Economic Outcomes From a Randomized Trial. Ann Thorac Surg 2018; 105:1344-1350. [DOI: 10.1016/j.athoracsur.2017.12.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/10/2017] [Accepted: 12/12/2017] [Indexed: 11/23/2022]
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21
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Marasco SF, Fuller L, Zimmet A, McGiffin D, Seitz M, Ch'ng S, Gangahanumaiah S, Bailey M. Prospective, randomized, controlled trial of polymer cable ties versus standard wire closure of midline sternotomy. J Thorac Cardiovasc Surg 2018; 156:1589-1595.e1. [PMID: 29778340 DOI: 10.1016/j.jtcvs.2018.04.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 04/04/2018] [Accepted: 04/09/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Midline sternotomy remains the most common access incision for cardiac operations. Traditionally, the sternum is closed with stainless steel wires. Wires are well known to stretch and break, however, leading to pain, nonunion, and potential deep sternal wound infection. We hypothesized that biocompatible plastic cable ties would achieve a more rigid sternal fixation, reducing postoperative pain and analgesia requirements. METHODS A prospective, randomized study compared the ZIPFIX (De Puy Synthes, West Chester, Pa) sternal closure system (n = 58) with standard stainless steel wires (n = 60). Primary outcomes were pain and analgesia requirements in the early postoperative period. Secondary outcome was sternal movement, as assessed by ultrasound at the postoperative follow-up visit. RESULTS Groups were well matched in demographic and operative variables. There were no significant differences between groups in postoperative pain, analgesia, or early ventilatory requirements. Patients in the ZIPFIX group had significantly more movement in the sternum and manubrium on ultrasound at 4 weeks. CONCLUSIONS ZIPFIX sternal cable ties provide reliable closure but no demonstrable benefit in this study in pain or analgesic requirements relative to standard wire closure after median sternotomy.
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Affiliation(s)
- Silvana F Marasco
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia.
| | - Louise Fuller
- Physiotherapy Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adam Zimmet
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David McGiffin
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Michael Seitz
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephanie Ch'ng
- CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
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22
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Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' Trial): a randomised trial. J Physiother 2018; 64:97-106. [PMID: 29602750 DOI: 10.1016/j.jphys.2018.02.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 12/23/2022] Open
Abstract
QUESTION In people who have undergone cardiac surgery via median sternotomy, does modifying usual sternal precautions to make them less restrictive improve physical function, pain, kinesiophobia and health-related quality of life? DESIGN Two-centre, randomised, controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS Seventy-two adults who had undergone cardiac surgery via a median sternotomy were included. INTERVENTION Participants were randomly allocated to one of two groups at 4 (SD 1) days after surgery. The control group received the usual advice to restrict their upper limb use for 4 to 6 weeks (ie, restrictive sternal precautions). The experimental group received advice to use pain and discomfort as the safe limits for their upper limb use during daily activities (ie, less restrictive precautions) for the same period. Both groups received postoperative individualised education in hospital and via weekly telephone calls for 6 weeks. OUTCOME MEASURES The primary outcome was physical function assessed by the Short Physical Performance Battery. Secondary outcomes included upper limb function, pain, kinesophobia, and health-related quality of life. Outcomes were measured before hospital discharge and at 4 and 12 weeks postoperatively. Adherence to sternal precautions was recorded. RESULTS There were no statistically significant differences in physical function between the groups at 4 weeks (MD 1.0, 95% CI -0.2 to 2.3) and 12 weeks (MD 0.4, 95% CI -0.9 to 1.6) postoperatively. There were no statistically significant between-group differences in secondary outcomes. CONCLUSION Modified (ie, less restrictive) sternal precautions for people following cardiac surgery had similar effects on physical recovery, pain and health-related quality of life as usual restrictive sternal precautions. Similar outcomes can be anticipated regardless of whether people following cardiac surgery are managed with traditional or modified sternal precautions. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ANZCTRN12615000968572. [Katijjahbe MA, Granger CL, Denehy L, Royse A, Royse C, Bates R, Logie S, Nur Ayub MA, Clarke S, El-Ansary D (2018) Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' Trial): a randomised trial. Journal of Physiotherapy 64: 97-106].
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Smereczyński A, Kołaczyk K, Bernatowicz E. Chest wall - underappreciated structure in sonography. Part II: Non-cancerous lesions. J Ultrason 2017; 17:275-280. [PMID: 29375903 PMCID: PMC5769668 DOI: 10.15557/jou.2017.0040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/16/2016] [Accepted: 12/20/2016] [Indexed: 12/04/2022] Open
Abstract
The chest wall is a vast and complex structure, hence the wide range of pathological conditions that may affect it. The aim of this publication is to discuss the usefulness of ultrasound for the diagnosis of benign lesions involving the thoracic wall. The most commonly encountered conditions include sternal and costal injuries and thoracic lymphadenopathy. Ultrasound is very efficient in identifying the etiology of pain experienced in the anterior chest wall following CPR interventions. Both available literature and the authors' own experience prompt us to propose ultrasound evaluation as the first step in the diagnostic workup of chest trauma, as it permits far superior visualization of the examined structures compared with conventional radiography. Sonographic evaluation allows correct diagnosis in the case of various costal and chondral defects suspicious for cancer. It also facilitates diagnosis of such conditions as degenerative lesions, subluxation of sternoclavicular joints (SCJs) and inflammatory lesions of various etiology and location. US may be used as the diagnostic modality of choice in conditions following thoracoscopy or thoracotomy. It may also visualize the fairly common sternal wound infection, including bone inflammation. Slipping rib syndrome, relatively little known among clinicians, has also been discussed in the study. A whole gamut of benign lesions of thoracic soft tissues, such as enlarged lymph nodes, torn muscles, hematomas, abscesses, fissures, scars or foreign bodies, are all easily identified on ultrasound, just like in other superficially located organs.
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Affiliation(s)
- Andrzej Smereczyński
- Self-education Sonography Group, Genetics Division, Pomeranian Medical University, Szczecin, Poland
| | - Katarzyna Kołaczyk
- Self-education Sonography Group, Genetics Division, Pomeranian Medical University, Szczecin, Poland
| | - Elżbieta Bernatowicz
- Self-education Sonography Group, Genetics Division, Pomeranian Medical University, Szczecin, Poland
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Fuller LM, El-Ansary D, Button BM, Corbett M, Snell G, Marasco S, Holland AE. Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial. Arch Phys Med Rehabil 2017; 99:1257-1264.e2. [PMID: 29042172 DOI: 10.1016/j.apmr.2017.09.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx). DESIGN Randomized controlled trial. SETTING Physiotherapy gym. PARTICIPANTS Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx. INTERVENTIONS All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment. MAIN OUTCOME MEASURES Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors. RESULTS After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P<.001) as well as greater UL strength than did participants in the NULP (mean peak force, 8.4±4.0Nm vs 6.7±2.8Nm; P=.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P=.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported. CONCLUSIONS UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.
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Affiliation(s)
- Louise M Fuller
- Physiotherapy Department, The Alfred Hospital, Melbourne, Victoria, Australia; Respiratory Department, The Alfred Hospital, Melbourne, Victoria, Australia; La Trobe University, Bundoora, Victoria, Australia.
| | - Doa El-Ansary
- Physiotherapy Department, The University of Melbourne, Carlton, Victoria, Australia
| | - Brenda M Button
- Physiotherapy Department, The Alfred Hospital, Melbourne, Victoria, Australia; Respiratory Department, The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Clayton, Victoria, Australia
| | - Monique Corbett
- Physiotherapy Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Greg Snell
- Respiratory Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Silvana Marasco
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anne E Holland
- Physiotherapy Department, The Alfred Hospital, Melbourne, Victoria, Australia; La Trobe University, Bundoora, Victoria, Australia
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Balachandran S, Sorohan M, Denehy L, Lee A, Royse A, Royse C, Ali KM, El-Ansary D. Is ultrasound a reliable and precise measure of sternal micromotion in acute patients after cardiac surgery? INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2017. [DOI: 10.12968/ijtr.2017.24.2.62] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
| | - Maeve Sorohan
- Senior physiotherapist, Royal Melbourne Hospital, Australia
| | - Linda Denehy
- Head of School of Health Sciences, The University of Melbourne, Australia
| | | | - Alistair Royse
- Cardiothoracic surgeon, deputy of surgery, Royal Melbourne Hospital and the School of Medicine, The University of Melbourne, Australia
| | - Colin Royse
- Specialist anaesthetist, The Royal Melbourne Hospital, and the School of Medicine, The University of Melbourne, Australia
| | | | - Doa El-Ansary
- Senior lecturer, The University of Melbourne, Australia
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Balachandran S, Lee A, Denehy L, Lin KY, Royse A, Royse C, El-Ansary D. Risk Factors for Sternal Complications After Cardiac Operations: A Systematic Review. Ann Thorac Surg 2016; 102:2109-2117. [DOI: 10.1016/j.athoracsur.2016.05.047] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/27/2016] [Accepted: 05/09/2016] [Indexed: 11/28/2022]
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El-Ansary D, Aitken J, Zalucki N, Hardikar A. Clinical management and rehabilitation of persistent sternal instability. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2015. [DOI: 10.12968/ijtr.2015.22.9.443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: Postoperative sternal complications after cardiac surgery remain a significant problem that increases hospital length of stay and cost of care, delays recovery, and impairs function. While the majority of patients with sternal instability can be successfully treated with sternal debridement and rewiring, this may not be an option for all patients who present with acute or persistent instability. Methods: This clinical case reports an interdisciplinary approach to the clinical assessment and conservative management of a complex patient with multiple co-morbidities and persistent sternal instability following three open-heart procedures for coronary revascularisation. It presents new and innovative diagnosis of sternal instability and monitoring of sternal healing using real-time ultrasound, as well as clinical management, with a sternal brace (QualiTeam, Chiaverano, 10010-Torino, Italy). Results: With the QualiBreath in situ, the patient reported a significant reduction in pain with activity (2/10), uninterrupted sleep and improved confidence in completing everyday tasks. On physical examination, there was minimal sternal motion on palpation (Sternal Instability Scale grade 1). Conclusions: A conservative interdisciplinary team approach to the management of patients who present with persistent sternal instability is recommended.
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Affiliation(s)
- Doa El-Ansary
- Senior lecturer in physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - John Aitken
- Senior cardiac rehabilitation nurse specialist, Department of Cardiology, Launceston General Hospital, Tasmania, Australia
| | - Nadia Zalucki
- Senior physiotherapist, Department of Physiotherapy, Launceston General Hospital, Tasmania, Australia
| | - Ashutosh Hardikar
- Senior cardiothoracic surgeon, Launceston General Hospital and Royal Hobart Hospital, Tasmania, Australia
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Upper limb exercise prescription following cardiac surgery via median sternotomy: a web survey. J Cardiopulm Rehabil Prev 2015; 34:390-5. [PMID: 24667665 DOI: 10.1097/hcr.0000000000000053] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Following cardiac surgery via median sternotomy, patients are routinely advised to adhere to upper limb restrictions to prevent the development of sternal complications. However, there is no definitive evidence to support the clinical application of such restrictions. The purpose of this study was to investigate current physiotherapy practice regarding upper limb exercise guidelines for this population, within outpatient cardiac rehabilitation in Australia. METHODS Physiotherapists working within outpatient cardiac rehabilitation programs in Australia were invited to complete a Web survey. RESULTS The response rate was 77%. The majority of respondents (96%) prescribed upper limb exercises to patients following median sternotomy, with 95% placing restrictions on these exercises. At 6 weeks postoperatively, 58% and 73% of respondents still placed restrictions on unloaded and loaded unilateral upper limb elevation exercises respectively; similarly, 55% and 74% placed restrictions on unloaded and loaded bilateral upper limb elevation exercises, respectively. However, there was a lack of consensus on the type and timing of these restrictions, with patient-reported pain being the main parameter used to guide upper limb exercise prescription and progression. Only 43% reported screening for sternal instability, and if detected, the majority based their management on clinical experience. CONCLUSIONS There is significant variation in practice with respect to the prescription and progression of upper limb exercises, within outpatient cardiac rehabilitation in Australia. Further research is warranted to establish evidence-based guidelines for the upper limb rehabilitation of patients following cardiac surgery via median sternotomy.
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Küçükdurmaz F, Ağır İ, Bezer M. Comparison of straight median sternotomy and interlocking sternotomy with respect to biomechanical stability. World J Orthop 2013; 4:134-138. [PMID: 23878782 PMCID: PMC3717247 DOI: 10.5312/wjo.v4.i3.134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/15/2013] [Accepted: 06/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To increase the stability of sternotomy and so decrease the complications because of instability.
METHODS: Tests were performed on 20 fresh sheep sterna which were isolated from the sterno-costal joints of the ribs. Median straight and interlocking sternotomies were performed on 10 sterna each, set as groups 1 and 2, respectively. Both sternotomies were performed with an oscillating saw and closed at three points with a No. 5 straight stainless-steel wiring. Fatigue testing was performed in cranio-caudal, anterio-posterior (AP) and lateral directions by a computerized materials-testing machine cycling between loads of 0 to 400 N per 5 s (0.2 Hz). The amount of displacement in AP, lateral and cranio-caudal directions were measured and also the opposing bone surface at the osteotomy areas were calculated at the two halves of sternum.
RESULTS: The mean displacement in cranio-caudal direction was 9.66 ± 3.34 mm for median sternotomy and was 1.26 ± 0.97 mm for interlocking sternotomy, P < 0.001. The mean displacement in AP direction was 9.12 ± 2.74 mm for median sternotomy and was 1.20 ± 0.55 mm for interlocking sternotomy, P < 0.001. The mean displacement in lateral direction was 8.95 ± 3.86 mm for median sternotomy and was 7.24 ± 2.43 mm for interlocking sternotomy, P > 0.001. The mean surface area was 10.40 ± 0.49 cm² for median sternotomy and was 16.8 ± 0.78 cm² for interlocking sternotomy, P < 0.001. The displacement in AP and cranio-caudal directions is less in group 2 and it is statistically significant. Displacement in lateral direction in group 2 is less but it is statistically not significant. Surface area in group 2 is significantly wider than group 1.
CONCLUSION: Our test results demonstrated improved primary stability and wider opposing bone surfaces in interlocking sternotomy compared to median sternotomy. This method may provide better healing and less complication rates in clinical setting, further studies are necessary for its clinical implications.
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Tewarie LS, Menon AK, Hatam N, Amerini A, Moza AK, Autschbach R, Goetzenich A. Prevention of sternal dehiscence with the sternum external fixation (Stern-E-Fix) corset--randomized trial in 750 patients. J Cardiothorac Surg 2012; 7:85. [PMID: 22958313 PMCID: PMC3579734 DOI: 10.1186/1749-8090-7-85] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 09/02/2012] [Indexed: 01/04/2023] Open
Abstract
Background The main objective of this study will be to determine the effects of a new advanced sternum external fixation (Stern-E-Fix) corset on prevention of sternal instability and mediastinitis in high-risk patients. Methods This prospective, randomized study (January 2009 – June 2011) comprised 750 male patients undergoing standard median sternotomy for cardiac procedures (78% CABG). Patients were divided in two randomized groups (A, n = 380: received a Stern-E-Fix corset postoperatively for 6 weeks and B, n = 370: control group received a standard elastic thorax bandage). In both groups, risk factors for sternal dehiscence and preoperative preparations were similar. Results Wound infections occurred in n = 13 (3.42%) pts. in group A vs. n = 35 (9.46%) in group B. In group A, only 1 patient presented with sternal dehiscence vs. 22 pts. in group B. In all 22 patients, sternal rewiring followed by antibiotic therapy was needed. Mediastinitis related mortality was none in A versus two in B. Treatment failure in group B was more than five times higher than in A (p = 0.01); the mean length of stay in hospital was 12.5 ± 7.4 days (A) versus 18 ± 15.1 days (B) (p=0.002). Re-operation for sternal infection was 4 times higher in group B. Mean ventilation time was relatively longer in B (2.5 vs. 1.28 days) (p = 0.01). The mean follow-up period was 8 weeks (range 6 – 12 weeks). Conclusions We demonstrated that using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence and secondary sternal infection in high-risk poststernotomy patients.
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Affiliation(s)
- Lachmandath S Tewarie
- Department of Cardiothoracic and Vascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany.
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Hautalahti J, Beev N, Hyttinen J, Tarkka M, Laurikka J. Postoperative sternal stability assessed by vibration: a preliminary study. Ann Thorac Surg 2012; 94:260-4. [PMID: 22734988 DOI: 10.1016/j.athoracsur.2012.01.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 01/10/2012] [Accepted: 01/11/2012] [Indexed: 12/01/2022]
Abstract
PURPOSE Mechanical stability of the postoperative sternum was assessed using novel analysis based on vibration response. DESCRIPTION The response to controlled vibration in the 50 Hz to 1,500 Hz range was studied in 22 elective cardiac surgical patients with an accelerometer, recorded, and processed on a personal computer. Each patient had four measurement sessions. The mechanical transfer function of the sternum was estimated, and several descriptive factors were extracted from it to determine how they reflect changes occurring in the bone during the recovery from sternotomy. EVALUATION Complete datasets were obtained from 14 patients. The most informative variable for the sternal healing was the P(600-1500) index, which reflects transmittance in the wide frequency band between 600 Hz and 1500 Hz. The index dropped after surgery, indicating a decrease in transmission. The postoperative measurements revealed a reverse trend in the same variable, which can be attributed to healing. CONCLUSIONS Significant changes caused by the sternotomy and subsequent healing processes were observed using vibration measurement.
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Affiliation(s)
- Juha Hautalahti
- Department of Cardiothoracic Surgery, Heart Center Co, Tampere University Hospital, Tampere, Finland.
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Management of sternal precautions following median sternotomy by physical therapists in Australia: a web-based survey. Phys Ther 2012; 92:83-97. [PMID: 21949431 DOI: 10.2522/ptj.20100373] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Sternal precautions are utilized within many hospitals with the aim of preventing the occurrence of sternal complications (eg, infection, wound breakdown) following midline sternotomy. The evidence base for sternal precaution protocols, however, has been questioned due to a paucity of research, unknown effect on patient outcomes, and possible discrepancies in pattern of use among institutions. OBJECTIVE The objective of this study was to investigate and document the use of sternal precautions by physical therapists in the treatment of patients following median sternotomy in hospitals throughout Australia, from immediately postsurgery to discharge from the hospital. DESIGN A cross-sectional, observational design was used. An anonymous, Web-based survey was custom designed for use in the study. METHODS The questionnaire was content validated, and the online functionality was assessed. The senior cardiothoracic physical therapist from each hospital identified as currently performing cardiothoracic surgery (N=51) was invited to participate. RESULTS The response rate was 58.8% (n=30). Both public (n=18) and private (n=12) hospitals in all states of Australia were represented. Management protocols reported by participants included wound support (n=22), restrictions on lifting and transfers (n=23), and restrictions on mobility aid use (n=15). Factors influencing clinical practice most commonly included "workplace practices/protocols" (n=27) and "clinical experience" (n=22). Limitations The study may be limited by response bias. CONCLUSIONS Significant variation exists in the sternal precautions and protocols used in the treatment of patients following median sternotomy in Australian hospitals. Further research is needed to investigate whether the restrictions and precautions used are necessary and whether protocols have an impact on patient outcomes, including rates of recovery and length of stay.
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El-Ansary D, Adams R, Waddington G. Sternal instability during arm elevation observed as dynamic, multiplanar separation. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2009. [DOI: 10.12968/ijtr.2009.16.11.44942] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Doa El-Ansary
- Faculty of Medicine, Dentistry and Health Sciences, School of Health Sciences, Department of Physiotherapy, University of Melbourne, Australia
| | - Roger Adams
- School of Physiotherapy, Faculty of Health Sciences, University of Sydney, Australia; and
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Sommer CM, Heye T, Stampfl U, Tochtermann U, Radeleff BA, Kauczor HU, Richter GM. Septic rupture of the ascending aorta after aortocoronary bypass surgery. J Cardiothorac Surg 2008; 3:64. [PMID: 19087260 PMCID: PMC2614984 DOI: 10.1186/1749-8090-3-64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Accepted: 12/16/2008] [Indexed: 11/24/2022] Open
Abstract
We describe an exceptional case of non-fatal septic rupture of the ascending aorta in a patient with sternal dehiscence, deep sternal wound infection (DSWI) and pleural empyema after aortocoronary bypass surgery. Routine follow-up computed tomography (CT) detected a mediastinal pseudoaneurysm originating from the ascending aorta. Thereby, massive and irregular sternal bone defects and contrast-enhancing mediastinal soft tissue suggest osteomyelitis and highly-active and aggressive DSWI as initial triggers. Urgent thoracotomy 1 day later included ascending aorta reconstruction, total sternum resection and broad wound debridement. Follow-up CT 1 year later showed a regular postoperative result in a fully recovered patient.
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Affiliation(s)
- Christof M Sommer
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
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Control of separation in sternal instability by supportive devices: a comparison of an adjustable fastening brace, compression garment, and sports tape. Arch Phys Med Rehabil 2008; 89:1775-81. [PMID: 18760163 DOI: 10.1016/j.apmr.2008.01.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 01/17/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of 3 supportive devices in controlling sternal separation. DESIGN A cross-sectional, randomized intervention study. SETTING Participants were from the general community who were referred to the study by their cardiac surgeon or cardiologist. PARTICIPANTS Fifteen patients (12 men, 3 women) between 49 and 80 years of age with sternal instability after a median sternotomy. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Support from sports tape, a compression garment, and an adjustable fastening brace was assessed by an ultrasound-based measure of sternal separation contingent on movement and by self-report measures of comfort, pain, feeling of support, ease of upper-limb movement, and ease of breathing. RESULTS For both sternal separation and self-report data, some support was better than no support, and a supportive device worn on the body was better than sports tape. Wearing an adjustable fastening brace was better than a compression garment and, compared with no support, closed the sternal gap by 20% or 2.7 mm (95% confidence interval, 1.5-3.9 mm). The effects of wearing the different supportive devices on visual analog scale ratings of comfort, pain, support, ease of breathing, and movement mirrored the results obtained for sternal separation, thus providing agreement between self-report and objective measures. CONCLUSIONS Supportive devices may be useful in the management of patients with sternal instability because wearing one resulted in a reduction of both sternal separation and pain report after movement. The largest effect was obtained from wearing an adjustable fastening brace.
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El-Ansary D, Waddington G, Adams R. Trunk stabilisation exercises reduce sternal separation in chronic sternal instability after cardiac surgery: a randomised cross-over trial. ACTA ACUST UNITED AC 2008; 53:255-60. [PMID: 18047460 DOI: 10.1016/s0004-9514(07)70006-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
QUESTION Do trunk stabilisation exercises reduce sternal separation and pain, and improve the quality and control of the performance of tasks in individuals with chronic sternal instability? DESIGN Randomised crossover study with concealed allocation and intention-to-treat analysis. PARTICIPANTS Nine individuals with chronic sternal instability following a median sternotomy for cardiac surgery. INTERVENTION The experimental intervention consisted of six weeks of trunk stabilisation exercises; the control intervention was no exercises. OUTCOME MEASURES Outcomes were sternal separation measured by ultrasound in mm, pain during the performance of nine everyday tasks measured on a 100-mm visual analogue scale, and the quality and control of the performance of two tasks scored on a 100-mm visual analogue scale. RESULTS Overall, sternal separation during the period of trunk stabilisation exercises decreased by 6.2 mm (95% CI 3.5 to 8.9) more than during the control period. Overall, pain decreased when performing everyday tasks by 14 mm (95% CI 5 to 23) more than during the control period. Overall, task performance during the period of trunk stabilisation exercises did not improve (mean difference 10 mm, 95% CI -3 to 22) more than during the control period. CONCLUSION Trunk stabilisation exercises should be included in the rehabilitation of individuals who experience sternal instability following cardiac surgery. A larger trial is warranted to determine if stabilisation exercises are beneficial in improving the quality and control of task performance.
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Magovern JA. Invited commentary. Ann Thorac Surg 2007; 83:1516-7. [PMID: 17383369 DOI: 10.1016/j.athoracsur.2006.11.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 11/06/2006] [Accepted: 11/15/2006] [Indexed: 10/23/2022]
Affiliation(s)
- James A Magovern
- Department of Cardiothoracic Surgery, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, USA.
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