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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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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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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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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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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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Fuller L, El-Ansary D, Nelson EM, Gooi J. External chest brace for clam shell sternal instability following bilateral sequential lung transplant: a case series. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2012. [DOI: 10.12968/ijtr.2012.19.4.233] [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: A common surgical incision for bilateral lung transplantation is the ‘clam shell’ approach via bilateral anterior thoracotomies and a transverse sternotomy to allow for the replacement of the lungs sequentially (Macchiarini et al, 1999; Karnak et al, 2006 ). Although popular, the clam shell incision (CSI) can be associated with significant postoperative pain, bony overriding or disruptions at the sternotomy site in 32%-60% of patients (Macchiarini et al, 1999; Venuta et al, 2003 ; Richards et al, 2004 ; Karnak et al, 2006 ). The subsequent non-union and sternal instability cause significant morbidity and mortality with reported rates of 34% and 26%, respectively ( Karnak et al, 2006 ). Content: The literature revealed a myriad of surgical approaches to this clinical problem, but a paucity of conservative external chest bracing solutions for transverse sternal instability. This case series describes the clinical management of three post bilateral sequential lung transplant (BSLTX) recipients that necessitated the design and development of a custom made external chest orthosis (brace) with input from a multidisciplinary team. Conclusion: This brace is offered as a solution for transverse sternal instability and pain following lung transplantation.
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Affiliation(s)
- Louise Fuller
- Transplant Services, Physiotherapy Dept, The Alfred Hospital Melbourne, Victoria, Australia
| | - Doa El-Ansary
- Physiotherapy Dept, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Elysia M Nelson
- Orthotic & Prosthethic Dept, The Alfred Hospital Melbourne, Victoria, Australia
| | - Julian Gooi
- Cardiothoracic Surgery Dept, The Alfred Hospital Melbourne, Victoria, Australia
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