Issn Print: 2158-8686

Publication Date: 2010/10/01


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Medial sternotomies: A systematic review and evidence-based guidelines for postoperative sternal precautions

Karen Tuttle; Andi B. Mincer; Anne W. Thompson

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Excerpt

Purpose/Hypothesis : Current postoperative guidelines for patients who have had a medial sternotomy vary widely in activities allowed and timeframes for recovery. This study combined a systematic review of peer-reviewed literature, popular web sources for patient information, and biomechanical analysis of activities of daily living (ADL) that are commonly limited during recovery from a medial sternotomy.
Number of Subjects : Three subjects were used for simple biomechanical analysis of sit to stand, push/pull, and lifting tasks.
Materials/Methods : Medline, PubMed, E-pub, and Galileo database searches were performed for peer-reviewed research articles, using “sternal precautions” and “sternal dehiscence” as keywords. Nursing and physical therapy texts and the American Association of Cardiovascular and Pulmonary Rehabilitation guidelines were reviewed. Additionally, dynamometry was used to establish the forces generated during various push, pull, and lift tasks.
Results : While the type of surgical closure influences sternal stability,sternal dehiscence occurs in less than 3% of sternotomies. Biomechanical forces from typical ADLs should not have enough force to distract the typical closure more than 2 mm,which is the threshold for potential dehiscence. Coughing presented the greatest risk. Risk factors include obesity, postoperative infection (i.e. pneumonia and urinary tract infections), diabetes mellitus, re-operations, harvesting of bilateral internal mammary arteries, and age greater than 60 years old.
Conclusions : Following medial sternotomy, all patients should be encouraged to (1) stabilize the chest by crossing their arms or hugging a pillow while coughing; (2) use lower extremities more than uppers when transferring from sit to stand; (3) use gentle, controlled motions when pushing, pulling, or lifting; (4) avoid resistance training and sports for three months with sternal stability testing prior to reengaging in these activities; and (5) immediately report any increased pain or feelings of instability in the sternum.
Clinical Relevance : Postoperative guidelines should allow patients the maximum freedom to resume normal mobility, yet appropriately restrict activities which may be harmful. This report incorporates evidence from peer-reviewed literature and biomechanical analysis to provide comprehensive sternal precautions following medial sternotomy.
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