Heart, Lung and Circulation

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


      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.


      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.


      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 0.01 cm, 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 (0.01–0.02 cm) 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.


      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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        • McGregor W.E.
        • Trumble D.R.
        • Magovern J.A.
        Mechanical analysis of midline sternotomy wound closure.
        J Thorac Cardiovasc Surg. 1999; 117: 1144-1449
        • Robicsek F.
        • Fokin A.
        • Cook J.
        • Bhatia D.
        Sternal instability after midline sternotomy.
        Thorac Cardiovasc Surg. 2000; 48: 1-8
        • Cahalin L.P.
        • LaPier T.K.
        • Shaw D.K.
        Sternal precautions: is it time for a change? Precautions versus restrictions – a review of literature and recommendations for revision.
        Cardiopulm Phys Ther J. 2011; 22: 5-15
        • Balachandran S.
        • Lee A.
        • Royse A.
        • Denehy L.
        • El-Ansary D.
        Upper limb exercise prescription following cardiac surgery via median sternotomy: a web survey.
        J Cardiopulm Rehabil Prev. 2014; 34: 390-395
        • Schell H.
        • Epari D.R.
        • Kassi J.P.
        • Bragulla H.
        • Bail H.J.
        • Duda G.N.
        The course of bone healing is influenced by the initial shear fixation stability.
        J Orthopaed Res. 2005; 23: 1022-1028
        • Wangsgard C.
        • Cohen D.J.
        • Griffin L.V.
        Fatigue testing of three peristernal median sternotomy closure techniques.
        J Cardiothorac Surg. 2008; 3: 1-9
        • El-Ansary D.
        • Waddington G.
        • Adams R.
        Relationship between pain and upper limb movement in patients with chronic sternal instability following cardiac surgery.
        Physiother Theory Pract. 2007; 23: 273-280
        • Bitkover C.Y.
        • Cederlund K.
        • Aberg B.
        • Vaage J.
        Computed tomography of the sternum and mediastinum after median sternotomy.
        Ann Thorac Surg. 1999; 68: 858-863
        • You J.
        • Chung Y.
        • Kim D.
        • Ching S.
        Role of sonography in the emergency room to diagnose sternal fractures.
        J Clin Ultrasound. 2010; 38: 135-137
        • El-Ansary D.
        • Waddington G.
        • Adams R.
        Measurement of non-physiological movement in sternal instability by ultrasound.
        Ann Thorac Surg. 2007; 83: 1513-1517
        • Balachandran S.
        • Sorohan M.
        • Denehy L.
        • Lee A.
        • Royse A.
        • Royse C.
        • et al.
        Is ultrasound a reliable and precise measure of sternal micromotion in acute patients after cardiac surgery.
        IJTR. 2017; 24: 2
        • El-Ansary D.
        • Adams R.
        • Waddington G.
        Sternal instability during arm elevation observed as dynamic, multiplanar separation.
        IJTR. 2009; 16: 609-614
        • El-Ansary D.
        • Waddington G.
        • Denehy L.
        • Flaherty M.
        • Fuller L.
        • Adams R.
        Physical assessment of sternal stability following a median sternotomy for cardiac surgery: validity and reliability of the Sternal Instability Scale (SIS).
        Int J Phys Ther Rehab. 2018; 4: 140
        • Deloach L.
        • Higgins M.
        • Caplan A.
        • Stiff J.
        The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale.
        Anesth Analg. 1998; 86: 102-106
        • Williamson A.
        • Hoggart B.
        Pain: a review of three commonly used pain rating scales.
        J Clin Nurs. 2005; 14: 798-804
        • Sturgess T.R.
        • Denehy L.
        • Tully E.
        • McManus M.
        • Katijjahbe M.A.
        • El-Ansary D.
        The Functional Difficulties Questionnaire: a new tool for assessing physical function of the thoracic region in a cardiac surgery population.
        J Cardiopulm Rehabil Prev. 2017; (Published ahead of print)
        • Corrales L.A.
        • Morshed S.
        • Bhandari M.
        • Miclau T.
        Variability in the assessment of fracture-healing in orthopaedic trauma studies.
        J Bone Joint Surg. 2008; 90: 1862-1868
        • Portney L.G.
        • Watkins M.P.
        Foundations for clinical research. Applications to practice.
        3rd ed. Pearson, New Jersey, NJ2009: 78-79 (183, 597-598)
        • 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.
        Aust J Physiother. 2007; 53: 255-260
        • Cnaan A.
        • Laird N.M.
        • Slasor P.
        Using the general linear mixed model to analyse unbalanced repeated measures and longitudinal data.
        Stat Med. 1997; 16: 2349-2380
        • Sturgess T.
        • Denehy L.
        • Tully E.
        • El-Ansary D.
        A pilot thoracic exercise programme reduces early (0-6 weeks) sternal pain following open heart surgery.
        IJTR. 2014; 21: 110-117
        • Adams J.
        • Lotshaw A.
        • Exum E.
        • Campbell M.
        • Spranger C.B.
        • Beveridge J.
        • et al.
        An alternative approach to prescribing sternal precautions after median sternotomy, “Keep Your Move in the Tube”.
        Proceedings (Baylor University. Medical Center). 2016; 29: 97-100
        • Stiller K.
        • Montarello J.
        • Wallace M.
        • Daff M.
        • Grant R.
        • Jenkins S.
        • et al.
        Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery.
        Chest. 1994; 105: 741-747
        • Filbay S.R.
        • Hayes K.
        • Holland A.E.
        Physiotherapy for patients following coronary artery bypass graft (CABG) surgery: limited uptake of evidence into practice.
        Physiother Theory Pract. 2012; 28: 178-187
        • Ji Q.
        • Mei Y.
        • Wang X.
        • Feng J.
        • Cai J.
        • Ding W.
        Risk factors for pulmonary complications following cardiac surgery with cardiopulmonary bypass.
        Int J Med Sci. 2013; 10: 1578-1583
        • El-Ansary D.
        • Waddington G.
        • Adams R.
        Control of separation in sternal instability by supportive devices: a comparison of an adjustable fastening brace, compression garment, and sports tape.
        Arch of Phys Med Rehabil. 2008; 89: 1775-1781
        • Moore K.L.
        • Dalley A.F.
        • Agur A.M.R.
        Clinically oriented anatomy.
        7th ed. Lippincott Williams & Wilkins, Pennsylvania, PA2014: 81-83