Precautions related to midline sternotomy in cardiac surgery: a review of mechanical stress factors leading to sternal complications

Background: After midline sternotomy patients are instructed on activity precautions to avoid sternal wound complications. We questioned how restrictive these precautions must be, since they can lead to a postoperative decrease in quality of life. Aims: To identify mechanical stress factors causing sternal instability and infection in order to create evidence based guidelines for activity following sternotomy. Methods: Literature review. Results: No evidence was found to support weight limitation regarding activity, as long as the upper arms are kept close to the body and activity is within a pain-free range. Recommendations: Avoid stretching both arms backwards at the same time (10 days); loaded activities should be done with the elbows close to the body (eight weeks); only move arms within a pain-free range; use leg rolling with counterweighing when getting in and out of bed; when coughing cross the arms in a "self-hugging" posture; supportive bra or vest is recommended when breast cup ≥ D, body mass index ≥ 35 or frequent cough. Conclusion: This study provides insights into mechanical stress factors acting upon sternum and the overlying skin. Recommendations on activity precautions based on these finding have a patient supportive approach focusing on possibilities and not restrictions.