Chest Wall Stabilization Research Articles

Hardware Preservation After Sternal Wound Infection in a Lung Transplant Recipient

Sternal wound infections can result in significant morbidity and mortality. Managing these complications is particularly challenging when infected hardware is involved. Traditional thinking mandates removal of infected hardware, yet this hardware is often essential to chest wall stability in the early postoperative period. Here, we present a case of an infected transverse sternotomy wound involving hardware in a lung transplant patient whose treatment included successful hardware preservation. Our experience and other experiences reported in the literature highlight the alternatives in the management of this complication.

Stabilization of the Chest Wall: Autologous and Alloplastic Reconstructions

The goals of chest wall stabilization include maintenance of a rigid airtight cavity, protection of the thoracic and abdominal contents, optimization of respiration, and, whenever possible, an aesthetic reconstruction. Evidence suggests that bony fixation results in reduced ventilator dependence, a shorter overall hospital stay, and improved upper extremity function. We prefer to accomplish this with autologous tissue alone (such as the pectoralis major, latissimus dorsi, or rectus abdominus muscle flaps) for small to moderate defects. En bloc resection of defects larger than 5 cm or containing four or more ribs will likely benefit from chest wall stabilization. For patients previously treated with radiation, even larger defects may be tolerated owing to fibrosis. For these larger defects, methyl methacrylate composite meshes are used and covered with vascularized tissue. Contaminated wounds are generally reconstructed with bioprosthetic mesh rather than synthetic mesh. Using these principles, the reconstructive plastic surgeon can devise a comprehensive and safe plan to repair tremendous defects of the chest wall.

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

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.

Chest wall reconstruction with two types of biodegradable polymer prostheses in dogs

Currently, the choice of chest wall prosthesis remains a challenging problem for thoracic and reconstructive surgeons. The purpose of this study is to investigate the feasibility of newly developed biodegradable prostheses. Two types of chest wall prostheses made from degradable polymer, collagen coated polydioxanone (CCP) mesh and chitin fiber reinforced polycaprolactone (CFRP) strut, were developed and studied. Adult mongrel dogs were subjected to extensive resection and reconstruction of anterior-lateral chest wall, CCP mesh was used in six dogs, the combination of CCP mesh and CFRP strut was used in four dogs, and polypropylene (PP) mesh in two dogs, as contrast. With good integration with tissue, CCP meshes maintained strength in the chest wall for more than 8 weeks and were completely resorbed within 24 weeks, and satisfactory short-term and long-term chest wall stabilization was achieved. The combined use of CCP mesh with CFRP strut provided a firmer chest wall in the early postoperative course. A mild wound infection developed in one animal with CCP mesh but resolved without sequelae, and no added complications were observed with the additional use of CFRP strut. Our experimental study shows that the CCP mesh and CFRP prosthesis were favorable for chest wall repair. The advantages of biodegradable copolymer give them promise as an excellent addition to the available reconstructive techniques currently in use.

ACUTE TOXOPLASMA GONDII INFECTION MANIFESTING AS MYOCARDITIS IN AN IMMUNE COMPETENT HOST

reports suggest that if removal of the foreign material can be delayed by several weeks, a strong fibrous layer will be formed that is rigid enough to provide chest wall stability. At present our patient remains on voriconazole and is contemplating delayed mesh removal. CONCLUSION: This case highlights that Aspergillus can be a delayed complication of prosthetic chest wall reconstruction. Its rarity is likely due to methylmethacrylate’s non porous nature and low capillarity. Issues for further discussion include the need for mesh removal based on experiences with bronchial stump Aspergillosis and the mechanism of infectionwhether the infection started in the pulmonary parenchyma with subsequent pleural and then chest wall extension or vice versa.

Utility of the Free Deep Inferior Epigastric Perforator Flap in Chest Wall Reconstruction

Breast cancer chest wall recurrence is often treated with chemotherapy, radical surgery, and radiation. Extensive chest wall resection requires soft-tissue reconstruction with tissue that provides chest wall stability and durability for additional radiation. Local and regional muscle and musculocutaneous flaps are often used for reconstruction. Free flaps, such as the transverse rectus abdominis musculocutaneous flap, are used for large defects, although donor site morbidity can result. The free deep inferior epigastric perforator (DIEP) flap provides coverage for large defects and may have less donor site morbidity. We describe the use of the free DIEP flap to reconstruct large chest wall defects (mean, 501 cm2 defects) after the resection of recurrent breast cancer in two patients. One patient had 2% flap loss. No donor site morbidity occurred. The free DIEP flap is a durable and reliable flap that provided immediate and complete coverage of these large chest wall defects with no donor site morbidity and did not delay the administration of adjuvant therapy.

Sternal resection and reconstruction for primary malignant tumors

Background Primary malignant sternal tumors (PMST) are locally aggressive and their optimal surgical management still continues to evolve. Methods From 1986 to 2002, 38 patients (25 females/13 males) underwent radical resection of PMST. This series included 33 sarcomas, 17 of which had been radiation-induced, 3 hematologic tumors, and 2 carcinomas. Seventeen were high-grade tumors. Nine patients had received preoperative chemotherapy. Twelve patients required extensive skin excision. Eight total, seven subtotal, and 23 partial sternectomies were performed. Resection was extended to the anterior chest-wall in 4 patients, lung in 4, brachiocephalic vein in 3, superior vena cava in 2, and pericardium in 1. In 36 patients, chest wall stability was obtained by Marlex (n = 21) or Vicryl (n = 2) mesh and polytetrafluoroethylene patch (n = 13), with methylmethacrylate reinforcement in 12 patients. Soft tissue coverage was done by the pectoralis major muscles with skin advancement in 25 patients, a myocutaneous flap in 11, a breast transposition in 1, and a skin flap in 1. Omentoplasty was performed in 3 patients. Results One patient died from pneumonia. Two patients needed a tracheostomy after total sternectomy. No flap-related complication was observed. Four local septic complications required removal of the composite prosthesis with reoperations. Local recurrence occurred in 9 patients, 7 patients having a repeat resection. Metastases developed in eight. The 5-year overall and disease-free survival was 66% and 53%, respectively. The histologic grade of sarcomas was a survival predictor (high grade versus others p = 0.035). Conclusions Wide resection of PMST is necessary to minimize local recurrence. Large sternal defects are safely reconstructed with a musculocutaneous flap. We suggest that the use of methylmethacrylate should be limited to reconstruction after total sternectomy.

Aortic and mitral valve surgery through a superior ministernotomy in pectus excavatum associated with Marfan's syndrome

The combination of chest wall abnormalities such as pectus excavatum and cardiac disease requiring operative correction represents a clinical challenge to the surgeon. We report two cases of patients with Marfan's syndrome and severe pectus excavatum in whom cardiac operations were successfully performed using a superior 'T inverted' ministernotomy. This approach allowed safe isolation of the target cardiac structures, provided excellent operative exposure and enhanced chest wall stability by preserving the integrity of the lower sternum.

Sternal fractures: retrospective analysis of 100 cases.

Isolated sternal fractures are seen with increasing frequency in road accidents, especially since the introduction of seatbelt legislation. The medical records of all our patients who were treated with a diagnosis of sternal fracture (SF) over the past two decades were retrospectively reviewed to determine the incidence, morbidity, and mortality of this entity. Between 1984 and 1998, 100 consecutive patients were admitted to the Department of Surge Surgery, General Hospital of Nikea-Piraeus, Greece, for SF. There were 72 men and 28 women ranging in age between 17 and 84 years. Sixty-seven patients sustained an isolated SF and the remaining 33 had a SF in combination with multiple injuries such as flail chest (n = 19), head injury (n = 18), limb fractures (n = 10), spinal fractures (n = 4), hear contusion (n = 1), hemo-pneumothorax (n = 9), pneumothorax (n = 6), hemomediastinum (n = 5), and pericarditis (n = 2), among others. All patients with a radiological diagnosis were admitted for cardiac monitoring for at least 24 hours. Electrocardiogram (ECG), determinations of cardiac enzyme levels such as lactic dehydrogenase, creatine kinase, and creatine kinase-MB, and evaluation by a cardiologist were routinely performed. An echocardiogram was performed as indicated by the cardiologist. Seven patients underwent operation, two for abdominal bleeding, two for chest wall and sternal stabilization, two for open pneumothorax, and one for massive hemothorax. Eight of our patients needed ventilatory support. Four of them died from respiratory insufficiency, myocardial infarction, and heart and lung contusion. Although an isolated SF carries a good prognosis, careful evaluation and clinical observation are essential.

Reappraisal of fascia lata grafts for reconstruction of chest wall defects.

Large chest wall defects require surgical reconstruction to ensure structural stability and to prevent flail chest. We used autologous fascia lata grafts to reconstruct skeletal chest wall defects in 8 consecutive patients. Sufficient chest wall stability was obtained; and no complications, such as flail chest, infection, or seroma, have been observed in any of the cases to date.

A rational approach to wound difficulties after sternotomy: reconstruction and long-term results

One hundred fifty-one patients were reconstructed after median sternotomy by a single plastic surgeon over a 6-year period. The treatment included immediate reconstruction (63 patients) and delayed reconstructions (88 patients). Ninety eight percent of the patients had definitive healing at 6 weeks with an overall 30-day mortality of 4 percent. The issues of long-term intravenous antibiotics, perceived skin deficiency, cardiac decompensation, Candida infections, and reexploration of a healed mediastinum after flap reconstruction are discussed. Follow up (4 months to 6 years) of patients treated with reconstruction compared favorably with patients treated with rewiring procedures (20 patients) in regard to strength, chest wall stability, pulmonary function testing, and functional return to hobbies and employment.

Operative stabilization of a flail chest six years after injury

We report a case of operative stabilization of an incompetent upper chest wall 6 years following flail chest. The indications for stabilization were chronic pain and dyspnea associated with rib malunion and loss of hemithorax volume. At operation, multiple pseudoarthroses were encountered and partial resection of ribs three and four was required. Malleable plates were used to bridge the gaps created by the resection and were secured in place with sternal wire. The patient reported a dramatic relief of symptoms and, at 18 months postoperatively, continues to work full-time on his cattle ranch essentially pain-free.

Management of flail chest

Flail chest continues to be a significant injury with serious complications. Controversy exists as to the optimal treatment. The principal dilemmas are whether the patient should be managed conservatively without mechanical ventilation, with ventilation, or via operative chest wall stabilization. This article illustrates a case of flail chest and summarizes the evidence for current treatment options.

Chest wall stabilization with synthetic reabsorbable material: E Puma, M. Ragusa, and G. Daddi. Ann Thorac Surg 67: 1823–1824, (June), 1999

Chest wall stabilization with synthetic reabsorbable material: E Puma, M. Ragusa, and G. Daddi. Ann Thorac Surg 67: 1823–1824, (June), 1999

Chest Wall Resection and Reconstruction

Chest wall reconstruction has been refined and expanded in recent years so that almost any defect may be repaired with an excellent cosmetic and physiological result. The first step in a good reconstruction is an appropriate and thorough resection that leaves healthy, viable margins to which the materials and tissues used in a reconstruction may be anchored securely. In most instances, chest wall stabilization will not be necessary. In some cases in which large areas of chest wall will be removed or a lateral aspect of a chest wall needs to be resected, stabilization may be necessary. Stabilization may also be required in patients who suffer from debilitating lung disease and need a chest wall resection and reconstruction. Soft tissue coverage completes the reconstruction by moving healthy, viable tissue to fill the defect. In most instances, pedicled muscular, musculocutaneous, and omental flaps will provide adequate soft tissue coverage. Very infrequently, a free flap will be necessary to achieve total closure of a chest wall defect. The soft tissue coverage is completed by using meshed, split thickness skin grafts to provide epithelialization of any exposed muscle or omentum.

Chest wall stabilization with synthetic reabsorbable materials as originally published in 1992: Updated in 1999 by

Chest wall stabilization with synthetic reabsorbable materials as originally published in 1992: Updated in 1999 by

Long-term observation in 68 patients operated on for pectus excavatum: surgical repair of funnel chest

Background. Recurrence after correction of pectus excavatum may sometimes occur, but its origin is not clear. The type of deformity, surgical technique, and patient lifestyle after operation can all affect the final shape of the thorax. The purpose of the present study was to compare the short-, medium-, and long-term cosmetic results of funnel chest repair. Methods. Sixty-eight patients (mean age, 12.1 ± 5.4 years; 48 male) were operated on for pectus excavatum using the same surgical technique: subperichondrial resection of the abnormal costal cartilages and stabilization of the elevated anterior chest wall with Kirschner’s wires. The patients were followed up every year (1 to 10 years) after operation, and the anterior chest wall contour was checked by physical examination and x-ray film. Results. Excellent to good cosmetic results 1 year after operation were achieved in 66 patients (97.1%). During the later follow-up period, a mild or moderate degree of recurrent sternal depression was noted in 6 patients (8.8%), teenagers only, 3 to 9 years after primary repair. Conclusions. Our technique for correction of pectus excavatum yields good short-term cosmetic results. Late recurrence of the deformity occurs during pubertal growth and does not appear to depend on surgical technique or length of follow-up.

Chest reconstruction in asphyxiating thoracic dystrophy

Asphyxiating thoracic dystrophy is a rare, complex malformation with a broad spectrum of clinical expression. Surgery is indicated only in severe cases in which failure to intervene will result in progressive pulmonary damage and eventual death. Conventional surgical techniques for expanding the thoracic cage diameter by sternotomy and the insertion of a metal prosthesis for anterior chest wall stability usually provide these patients with the time needed for thoracic cage growth. However, some of the most severe cases may require a two-stage approach. Hence, management should be directed toward resolving immediate ventilatory problems and minimizing secondary damage to the lungs caused by prolonged ventilatory support.

Operative chest wall stabilization in flail chest—outcomes of patients with or without pulmonary contusion

Background: The aim of operative chest wall stabilization in patients with flail chest and respiratory insufficiency is to reduce ventilator time and avoid ventilator associated complications. The purpose of this retrospective study was to analyze the indications and outcomes of operative chest wall stabilization in defined groups of patients sustaining flail chest with and without pulmonary contusion. Methods: The hospital records of 405 patients with multiple trauma (Injury Severity Score > 17) between 1988 and 1994 were reviewed. Forty-two patients sustained flail chest. Twenty of these underwent operative chest wall stabilization for the following indications: 1) flail chest with indication for thoracotomy due to intrathoracic injury (n = 6); 2) flail chest without pulmonary contusion (n = 9); 3) paradoxical movement of a chest wall segment in the weaning period from the respirator (n = 3); and 4) severe deformity of the chest wall (n = 2). For the purpose of analysis the patients were separated into groups: group 1: operative chest wall stabilization in flail chest without pulmonary contusion (n = 10); group 2: operative chest wall stabilization in flail chest with pulmonary contusion (n = 10); group 3: flail chest without pulmonary contusion and without chest wall stabilization (n = 18); group 4: flail chest with pulmonary contusion and without chest wall stabilization (n = 4). Data were coded for time of operation, duration of ventilatory support, and complications. Results: There were no significant differences in age, severity of injury, and extent of injury between groups 1, 2, and 3 (p < 0.42). Group 4 was excluded for statistical analysis because of the small number of patients. Patients in group 1 required a shorter ventilatory support time compared to patients in group 3 (6.5 ± 7.0 versus 26.7 ± 29.0 days) and group 2 (p < 0.02). In group 2 (ventilator time 30.8 ± 33.7 days) early extubation was only possible in patients being operated on for chest wall instability during weaning from the ventilator. One patient in group 1, three patients in group 2 and five patients in group 3 developed pneumonia with further disturbance of gas exchange. All patients in group 1 survived; deaths in group 2 were attributed to massive hemorrhage in two and septic multiorgan failure in one patient. Four patients in group 3 died of head injury, one of acute respiratory distress syndrome, one of severe hemorrhage, and one of multiple organ failure. Conclusions: In patients with flail chest and respiratory insufficiency without pulmonary contusion, operative chest wall stabilization permits early extubation. Patients with pulmonary contusion do not benefit from chest wall stabilization. Secondary operative chest wall stabilization in these patients is indicated when progressive collapse of the chest wall is evident during weaning from the ventilator.

Resection and reconstruction of sternum

In case of sternal resection, it is necessary to preserve bone material indispensable for the stability of the anterior chest wall and air tightness of the thoracic cavity, and the support of the chest wall integrity must be restored by some means. Various techniques have been applied to the reconstruction of the chest wall following resection. During the last 10 years, we have performed reconstructive operation for 6 cases of the chest wall following resection of the sternum in recurrent cases of breast cancer or invaded case of primary breast cancer. In these patients, the chest wall was reconstructed using a rib-latissimus dorsi osteomyocutaneolus flap or a latissimus dorsi myocutaneous flap. The sternum was totally resected in 3 cases, and in all 3 cases, reconstructed using a rib-latissimus dorsi osteomyocutaneous flap. Although postoperative pulmonary function decreased, all cases could be relieved from endotracheal intubation within 17 hours after operation, and had no problems in activities of daily living or occurrence of chest flailing or paradoxical movement of the chest. An artificial material (expanded polytetrafluoroethlene patch) was used in only one patient for the reconstruction of the osseous thorax, but this case developed infection during postoperative chemotherapy. After this experience, we used only biological materials for the reconstruction of the chest wall and postoperatively performed radiotherapy and/or chemotherapy on all cases. We have observed no flap infection or detachment since then. One characteristic of using the latissimus dorsi myocutaneous flap is that it is easily elevated and rarely causes serious postoperative esthetic or functional problems. The flap is also easily utilized to reinforce the osseous thorax because ribs immediately below the latissimus dorsi muscle are readily mobilized as a pedicle graft. Reconstruction of the chest wall following resection of the sternum, described in this report, allowed us to perform radiotherapy and/or chemotherapy without serious postoperative complications on the cases relapsing after treatment of breast cancer. The 2-year survival rate is 50% and one of these cases survived up to 10 years after resection of the sternum. Thus we prefer to perform resection of the sternum for sternal recurrence of breast cancer if there are no metastatic lesions in other organs.