Composite chest wall reconstruction using titanium plates and mesh preserves chest wall function

Abstract

Although multiple techniques have been used to correct chest wall defect, the impact of these on chest wall function (chest wall mechanism/pulmonary function) is poorly studied.1Bibas B.J. Bibas R.A. Operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate.Eur J Cardiothorac Surg. 2006; 29: 1064-1066Crossref PubMed Scopus (14) Google Scholar In our experience, composite chest wall reconstruction using titanium plates and mesh correct both the cosmetic and physiologic abnormalities.2Cicilioni Jr., O.J. Stieg 3rd, F.H. Papaniculaou G. Sternal wound reconstruction with transverse plate fixation.Plast Reconstr Surg. 2005; 115: 1297-1303Crossref PubMed Scopus (73) Google Scholar, 3Voss B. Bauernschmitt R. Will A. et al.Sternal reconstruction with titanium plates in complicated sternal dehiscence.Eur J Cardiothorac Surg. 2008; 34: 139-145Crossref PubMed Scopus (81) Google Scholar, 4Lee T.Y. Estrera A.L. Safi H.J. Khalil K.G. Total sternal reconstruction using a titanium plate-supported methyl methacrylate sandwich.Ann Thorac Surg. 2007; 84: 664-666Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Surgical reconstruction was performed in 13 patients using a Titanium Fixation System (Synthes, West Chester, Pa); Figure 1, A, consisting of titanium plates and self-tapping unlock screws. All plates can be joined by U-shaped release pins, which allows quick and easy surgical access in case of reoperations. There were 3 patients groups (Table 1). In groups A and B, rib reconstruction was performed with titanium plates and a dual-mesh patch was placed and fixed to the plates to avoid direct contact between prosthesis and lung parenchyma (Figure 1, B).Table 1Personal observationPatient (age)DiagnosisSurgical treatmentSurgical reconstructionPreoperative FEV1 (L)Postoperative FEV1 (L)Group A 1 (47 y)SarcomaV, VI, VIIV, VI2.672.80 (+4.8%) 2 (82 y)SarcomaV, VI, VIIV, VI2.962.78 (−6.1%) 3 (56 y)Metastasis from sarcomaV, VIV1.311.25 (−4.5%) 4 (58 y)TraumaVI, VIIVI, VII2.101.99 (−5.2%) 5 (71 y)TraumaIV, V, VIIV, VI1.641.65 (+0.6%)Group B 6 (54 y)NSCLCUpper lobectomy (III, IV, V)III, V2.491.97 (−20.9%) 7 (48 y)NSCLCUpper lobectomy (III, IV, V)III, V2.801.71 (−38.9%) 8 (64 y)NSCLC(clavicle, I, II, III)Clavicle, II1.420.98 (−30.9%) 9 (56 y)Malignant pleural mesotheliomaLeft extrapleural pneumonectomy (II, III, IV, V, VI)III, IV, VI2.611.36 (−47.8%)Group C 10 (65 y)InfectionTotal sternectomyManubrium and sternum1.491.55 (−4.0%) 11 (48 y)Renal metastasisSubtotal sternectomySternum—— 12 (49 y)FracturePartial sternectomySternum2.982.89 (−3.0%) 13 (69 y)FractureOsteosynthesisSternum——Group A, Rib resection; group B, lung and rib resection; group C, sternal resection; NSLC, non–small cell lung cancer; FEV1, forced expiratory volume in 1 second. Open table in a new tab Group A, Rib resection; group B, lung and rib resection; group C, sternal resection; NSLC, non–small cell lung cancer; FEV1, forced expiratory volume in 1 second. In group C, the first patient, in particular, received an en bloc sternectomy for sternum infection after cardiac surgery, and then 4 titanium plates were fixed to the clavicle and to both sides of the second, fourth, and fifth rib, respectively, successively covered with a titanium patch.5Iarussi T. Marolla A. Pardolesi A. Patea R.L. Camplese P. Sacco R. Sternectomy and sternum reconstruction for infection after cardiac surgery.Ann Thorac Surg. 2008; 86: 1680-1681Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In all cases of sternum resection, a bilateral pectoralis major muscle flap was carried out to cover the prosthesis. There was no postoperative mortality. A subcutaneous seroma occurred in 2 patients and atrial fibrillation and prolonged air leakage in 1 patient. A 3-day stay in the intensive care unit was required for hemodynamic instability in a patient with malignant mesothelioma having extrapleural pneumonectomy and chest resection. All the other patients were extubated immediately at the end of the surgical procedures. Pre- and postoperative data showed a good preservation of respiratory function even after lung resection if compared with predictive values (Table 1). The reported technique leads to chest wall stability and physiologic mobility preservation, allowing quick patient mobilization and participation in respiratory rehabilitation programs. Plates can be easily shaped to replace removed ribs, even in cases of bad bone quality. In cases of large chest wall defect, stability can be obtained without rebuilding each rib removed. In cases of removal of 3 or 4 ribs, for example, chest cage stability can be obtained with reconstruction of 2 ribs. Data from our experience, even if consisting of few cases, support the practical utility of titanium plate application for rib and sternal reconstruction.