• Postoperative osteopathic manipulative management of median sternotomy patients JERRY L. DICKEY, DO More than 250,000 patients geons are also using this incision in pulmo- yearly undergo coronary bypass graft sur- nary procedures. Attendant to the more wide- gery accomplished via the median ster- spread use of this operative approach has been notomy incision, an approach that has an increase in the number of patients who are been gaining widespread acceptance. This being seen with structural complaints postop- surgical approach has been associated eratively. Current medical literature docu- with a growing number of patients with ments the more dramatic consequences but structural complaints. This article de- fails to relate more subtle changes in chest scribes a postoperative treatment proto- cage mechanics resulting from the use of this col for improving healing and reducing approach. musculoskeletal disability associated with The purpose of this article is to suggest an such cardiac procedures and presents a osteopathic treatment regimen that addresses logical sequence of treatment graded to these alterations of anatomy and physiology. the patients changing condition and stage of healing. The author challenges the os- Incidence teopathic medical profession to meet the Although it is difficult to pinpoint the precise opportunity that exists to educate patients number of surgical procedures in which the and physicians about the benefits of os- median sternotomy approach is used, the num- teopathic healthcare. ber in the United States probably exceeds 250,000 per year. The sharp increase in coro- There has been increasing acceptance of the nary bypass graft procedures for the treatment use of the median sternotomy approach in in- of coronary insufficiency contributes the larg- trathoracic surgical procedures. It is the pre- est single group of patients undergoing me- ferred approach for cardiac surgical proce- dian sternotomy. From 1979 to 1982, there was dures, and a growing number of thoracic sur- a 48% increase in the number of coronary by- pass graft procedures 2; in 1983, there were a reported 191,000 such procedures performed in the United States. 3 The increasing use of Dr Dickey is chairman of the department of manipulat- coronary bypass graft surgery, in addition to ive medicine, Ibxas College of Osteopathic Medicine, other open heart and pulmonary procedures, Fort Worth. He wrote this thesis as part of the require- ment for Fellowship certification in the American Acad- could push the number of median sternotomies emy of Osteopathy. to more than 400,000 per year in the near fu- ture. Such numbers behoove the osteopathic Reprint requests to Jerry L. Dickey, DO, chairman, de- medical profession to develop treatment ap- partment of manipulative medicine, lexas College of Os- proaches that will address the postoperative teopathic Medicine, 3500 Camp Bowie Blvd, Fort Worth, structural needs of this enlarging population. TX 76107-2690. JAOA • Vol 89 • No 10 • October 1989 • 1309 Clinical practice • Dickey Common operative approach Treatment plan In the common operative technique for median All of the complications reported in the litera- sternotomy, the surgeon divides the skin with ture are readily observed in the immediate post- a rectilinear median incision from the supra- operative period. The literature fails to men- sternal notch to below the xiphoid process and tion the structural and functional changes in uses diathermy to separate the subcutaneous chest cage mechanics that do not become evi- layers and achieve hemostasis. The surgeon dent until weeks, or even months, after sur- then divides the sternum by use of an electric gery. Of interest to the osteopathic physician bone saw and covers the exposed edges with are hypomobility and somatic dysfunction of bone wax.4 Next, the operator retracts the ster- the thoracic vertebrae and rib cage, disruption num by use of an Ankeney retractor, with the of fascial patterns through the mediastinum, upper end placed at the level of the second rib. back pain (thoracic), and limited or distorted For cardiac procedures, the pericardial sac is dysfunction of the diaphragm. opened to expose the heart. The treatment plan proposed here addresses Following the surgical procedure, some sur- these potential sequelae as they arise, start- geons close the pericardium, while others in- ing with the preoperative phase and continu- completely close the pericardium to allow bet- ing through the immediate postoperative pe- ter drainage. The cut sternal margins are ap- riod to approximately 6 months postopera- proximated with four to six stainless steel fig- tively. ure-of-eight sutures. The superficial tissues usu- ally are closed with cutaneous absorbable su- Preoperative treatment plan tures. Pericardial, substernal, and pleural Ideally, the osteopathic physician should as- drainage tubes exit the chest below the xiphoid sess the patients rib cage function preopera- process. tively, noting and recording symmetry or asym- metry and breathing patterns, including depth Common sequelae of respiration as a function of diaphragmatic The common postoperative sequelae reported excursion. Somatic dysfunction of the cervical in the literature include wound dehiscence, sub- vertebrae should be mobilized in preparation sternal and pericardial infection, nonunion of for intubation. Somatic dysfunction of the tho- the sternum, pericardial constriction, phrenic racic vertebrae and ribs should be treated to nerve injuries, rib fractures, and brachial optimize tidal volume, and lumbar restriction plexus injuries. The last two sequelae are of should be improved to aid the excursion of the particular interest because they are probably diaphragm. Unfortunately, all too often the os- related. teopathic physician does not see the patient Studies have placed the incidence of bra- until after surgery, and so has not had the op- chial plexus injuries as high as 23.5%. 5 Van- portunity to assess preoperative function. der Salm and associates5 performed median One should attempt to impress on the sur- sternotomies on ten cadavers using the com- geon the importance of anatomically accurate mon surgical approach previously described. approximation of the sawed sternal halves. Seven of the ten cadavers sustained first rib The function of the sternal angle of Louis is fractures, with the fractured ends of the ribs vital to the proper function of the upper rib often impaling the lower trunks of the brachial cage. It is not uncommon for surgeons to ac- plexus. These investigators operated on an ad- cept discrepancies of 0.25 inch when suturing ditional ten cadavers in which they placed the the sternal halves. Such malalignment may upper end of the Ankeney retractor at the level well adversely affect sternal and rib cage of the fourth rib instead of at the level of the mechanics. second rib, and they observed no rib fractures.5 Such fractures usually are occult and are de- Early postoperative treatment plan tected only by radioactive isotope bone scan- Usually, it is not until the postoperative pe- ning; many go unrecognized. riod that the osteopathic physician sees the pa- 1310 • JAOA • Vol 89 • No 10 • October 1989 Clinical practice • Dickey Figure 1. Testing fascial patterns of the chest. tient who has undergone median sternotomy. The upper four ribs usually are more se- Ideally, one should begin assessment and treat- verely injured as a result of the placement of ment as soon as possible after the patients dis- the Ankeney retractor. Upper ribs normally missal from surgery and before there has been have less mobility than lower ribs owing to time for the sequelae associated with healing their firmer attachment, posteriorly to the ver- to develop. Certainly, a month postsurgery is tebrae and anteriorly to the sternum. The wide not too soon to begin treatment. retraction necessary for the median sterno- The proposed treatment plan is based on the tomy approach places more mechanical force assumption that functional healing of the ster- on the upper than on the lower ribs. Intercos- num is incomplete. Modifications in type of tal muscle contraction is usually present, as treatment and duration are made as healing is dysfunction and focal contraction of the dia- continues. Since the majority of median ster- phragm. notomy patients will have undergone coronary With the patient in the supine position, the bypass graft surgery, it is likely that this pa- physician evaluates the patterns of injury to tient population is in the sixth and seventh the chest and sternum by placing one hand decades of life. Such patients likely will have between the scapulas (Fig 1) while placing and chronic musculoskeletal problems and os- resting the other hand on the skin in the teoarthritis that predate the surgical insult. midline of the sternum. Turning each hand in- Chronic obstructive pulmonary disease and dependently in a clockwise, then counterclock- other chronic disease states may further com- wise direction, will reveal the tissue prefer- plicate the assessment. ence pattern. These findings should be re- The initial step is to repeat the evaluation corded because they usually change through previously described here for the preoperative the course of treatment. assessment. Even if presurgical data are not Treatment consists of gently encouraging available, postsurgical evaluation of breath- both anterior and posterior tissue preference ing patterns and chest cage symmetry is help- patterns and holding them until tissue tension