Novel hardening bone putty enhances sternal closure and accelerates postoperative recovery

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.

Comparison of Two Techniques Performing the Supine-to-Sitting Postural Change in Patients with Sternotomy

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.

Trunk stabilising exercises promote sternal stability in patients after median sternotomy for heart valve surgery: a randomised trial

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.

External chest brace for clam shell sternal instability following bilateral sequential lung transplant: a case series

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.