Rib Segments Research Articles

Technique of Video-Assisted Thoracoscopic Chest Wall Resection

c t m ( s w s Operative procedures used for cancerous chest wall invasion involve complete resection of the lung mass en loc with adjacent segments of ribs, traditionally involving a otentially disfiguring resection, lengthy hospitalization, and painful and protracted recovery period. As video-assisted horacoscopic surgery experience has grown, the proportion f patients deemed suitable for this type of approach as oposed to the traditional thoracotomy for lung resection has ncreased. Although experience with this approach is still merging, there is sufficient evidence demonstrating dereased morbidity and hospital stays with oncologic equivaency.1-3 As thoracoscopic resection for lung cancer evolved and became our predominant approach with the ability to perform an equivalent dissection to open procedures, we have naturally extended its indications to more complex situations. There have been few reports of thoracoscopic chest wall resection in an en bloc fashion, possibly because the perception that any benefit gained by avoiding rib spreading and the incision of other chest wall tissue would be eclipsed by perturbing the rib cage.4,5 For those interested in pursuing en bloc thoracoscopic resection, patients whose chest wall invasion lies near enough to an access incision favorable for lung resection and who require resection of 4 or fewer ribs are optimal candidates. The staging workup for all patients with chest wall invasion includes preoperative computed tomography scans in addition to positron emission tomography demonstrating no evidence of metastatic disease prior to being considered for chest wall resection. Moreover, preoperative imaging should demonstrate that the musculature and soft tissues superficial to the rib are uninvolved. Patients with larger tumors or with hilar lymph node involvement may not be suitable candidates for the hybrid approach secondary to limited mobility of the tumor and

Video-Assisted Thoracic Surgery Rib Resection and Reconstruction With Titanium Plate

A 38-year-old man was diagnosed with fibrous dysplasia of the anterolateral segment of the fifth rib by core biopsy. A decision was made to resect the rib by video-assisted thoracic surgery (VATS) taking care to preserve the muscle and overlying myodermal layers. Subsequent reconstruction was done using a straight titanium plate locked in place under thoracoscopic guidance to avoid friction of the plate on the skin and to verify that the transfixed screws would not injure the lung or the pericardium. The patient made an uneventful recovery and was dismissed on day 2 after surgery. Final diagnosis confirmed fibrous dysplasia.

The Use of Veritas Collagen Matrix to Reconstruct the Posterior Chest Wall After Costovertebrectomy

Among the new materials introduced for chest wall reconstruction, the use of collagen matrix is gaining increasing favor for its biomechanical properties. We describe the reconstruction of the chest wall with Veritas (Synovis, St Paul, MN) collagen matrix of a posterior chest wall defect after costovertebrectomy for Ewing's sarcoma. En bloc resection was performed, including partial D7 through D9 vertebrectomy along with the posterolateral segments of corresponding ribs. The collagen matrix patch was sutured to the spine stabilizer and the surrounding rib segments and was covered by previously raised latissimus dorsi and trapezius muscle flaps. Excellent stabilization was obtained.

Structural response and strain patterns of isolated ribs under lateral loading

Efforts to mitigate thoracic injury under lateral impact require an understanding of the structural and fracture characteristics of individual ribs under lateral loading. While a number of studies have loaded segments of rib under three-point bending, this study is the first to investigate lateral loading onto entire ribs. Fifteen individual ribs were extracted, positioned upright and a lateral displacement at 1 m/sec was applied. Displacements at the time of fracture were relatively constant across rib levels at 18.3 ± 3.7 mm. Fracture forces ranged from 27 N to 270 N at the anterior extremity and 103 N to 326 N at the posterior extremity; this was also insensitive to rib number. The strain gages indicated that the point immediately opposite the loader on the rib's internal surface experienced the highest tensile strains, while elsewhere the internal surface was in compression and the external surface was in tension. This structural-level rib characterisation can help to better understand the mechanisms of thoracic injury under lateral impact.

Overall and Step Iterative Algorithm of Cable Force for Multi-Rib Steel Truss Arch Bridge in Procedure of Rib Segments Assembling

Taking deformation of the main arch under dead load as the arch alignment control target, the overall cable force and pre-camber of multi-rib arch were calculated by zero-order optimization method. According to the installation sequences of arch segments, taking deviation of cable tower, cables in one-time tensioning method and the section stress of arch chords as constraint conditions, the cable force and pre-camber for every segment were calculated by iterative method. This method is applied to the erection of a 400m steel truss arch bridge with three ribs, the calculated values of cable force are anastomosed with the measured ones, and the precision of arch alignment is high.

Secondary Tuberculosis of Breast: Case Report

Tuberculosis of breast is a rare disease which is difficult to differentiate from carcinoma of breast. The involvement of breast can be primary or secondary to some focus in body. A case of secondary tuberculosis of right breast in a 21-year-old female from Kashmir, India, is being reported. Presentation was as a painless discharging sinus of right breast. A tubercular foci of rib was the affecting source of disease. No other evidence of tuberculosis was present in the body. Resection of involved rib segment, along with the discharging sinus, was performed. The patient had antitubercular therapy for 9 months, with no recurrence seen in followup.

Aphallia, Lung Agenesis and Multiple Defects of Blastogenesis

We report the association of aphallia, with imperforate anus, bilateral renal dysplasia and complete right lung agenesis in a fetus born of non-consanguineous parents. No maternal diabetes was present. The multiple mesodermal anomalies present in this male fetus, with a severe form of Uro-Rectal-Septum Malformation Sequence associated with unilateral lung agenesis, and rib segmentation anomaly is consistent with an extended defect of blastogenesis, with apparent common timing of the malformations around the 5th to 7th weeks of gestation.

Invited Commentary

Invited Commentary

Repair of Tracheomalacia With Inflammatory Defect and Mediastinitis

We describe a novel repair of an anterior inflammatory tracheal defect with mediastinitis, which occurred after external tracheal suspension of localized intrathoracic tracheomalacia. The malacic tracheal segment of 4-cm length containing the inflammatory tracheal defect was noncircumferentially resected. A temporary endotracheal silicone stent was introduced, and the trachea was closed by a pedicled pectoralis muscle flap reinforced with an embedded rib segment. Retrieval of the stent 5 months postoperatively resulted in a re-epithelialized, persistently stable, noncollapsible tracheal segment that showed the same diameter and configuration as the nonreconstructed part of the trachea.

Nanning Butterfly Tied Arch Bridge Over the Yong River in China

The Nanning Butterfly Tied Arch is a unique three-dimensional (3D) arch that incorporates several design and analysis innovations. The curved orthotropic deck with a horizontally draped internal tie resists both arch thrust and serves as a horizontal arch to resist out-of-balance lateral forces imparted by the asymmetric arch ribs. This force resisting system was confirmed and refined by 3D shape-finding studies. The arch rib segments are orthotropic boxes, which is a first for long span arches. And most notably, this is the last bridge worked on by the late Prof. T.Y. Lin.

Large Experimental Fistula of the Right Dorsal Colon in Horses

Studies in horses with experimental gastrointestinal fistulas may lead to rapid advancements in equine nutrition, as well as prevention and treatment of diseases such as colic and laminitis. The aim of this study was to devise a technique and a cannula to create a large fistula in the right dorsal colon (RDC). A total of 13 horses with normal gastrointestinal tract were used. After the administration of sedatives and local anesthetics, a segment of the right 16th rib was removed, a circular defect was created in the muscular wall, and the RDC was sutured to the muscular wall. The subcutaneous tissue and skin were closed over the attached RDC in eight horses (closed technique), or removed to expose the serosa of the colon sutured to the abdominal wall in five horses (open technique). A full thickness circular incision was made 2 to 6 weeks later to create a fistula. A cannula (diameter, 5 cm) made of natural rubber or silicon was inserted in the fistula. The open surgical technique was easier to perform and resulted in fewer complications. The cannula made of silicon resulted in less pruritus. One horse had a large colon torsion around the colopexy before fistula creation. One of the 12 fistulated horses had a large colon displacement 43 days after cannula insertion. These observations suggest that pexis of the RDC may predispose the horse to large colon displacement or volvulus. The open technique for the colopexy and the cannula made of silicon can be used for creation of a RDC fistula.

Current indications and results for thoracoplasty and intrathoracic muscle transposition

Thoracoplasty has lost much of its popularity and is being supplanted by space-reduction operations using muscle flaps. Our purpose is to retrospectively study the remaining indications and the evolving modifications of this ancient technique in our current surgical practice. From 1994 to 2008, 35 patients underwent a thoracoplasty procedure in a single thoracic surgery centre for treatment of infectious complications of previous thoracic surgery. The number and length of ribs excised were dictated by the size and location of the thoracic cavity to obliterate. Muscle flaps were used to buttress bronchial fistulas and to fill out residual spaces. We reviewed the immediate and long-term results concerning infection control and procedure tolerance. The infectious complications of previous thoracic surgery were related to cancer in 25, tuberculosis in six, oesophageo-pleural fistula in two, ruptured lung abscess and pleural thickening in one each. The thoracoplasty procedure was performed for: (1) post-pneumonectomy empyema, n=20 (bronchial fistula, n=11; open window thoracostomy, n=14; mean number of resected ribs, n=7.5; associated intrathoracic muscle transposition, n=12; postoperative death, n=3); (2) post-lobectomy empyema, n=8 (bronchial fistula n=8; open window thoracostomy n=1; mean number of resected ribs n=3.6; associated intrathoracic muscle transposition n=7; no death); (3) other indications, n=7 (mean number of resected ribs n=4.8; associated intrathoracic muscle transposition n=3; no death). All patients discharged from the hospital except one were cured and did not complain of symptoms of secondary lung function and shoulder impairment. Although thoracoplasty is rarely indicated nowadays, this does not imply that the procedure should be avoided. Thoracoplasty may be associated with myoplasty, which permits achieving complete space obliteration by combining resection of a few rib segments and limited intrathoracic muscle transposition.

Biomechanical properties of the costovertebral joint

Proper modeling of the human trunk requires a quantitative assessment of the stiffness of the costovertebral joints. Twelve samples (adjacent thoracic vertebrae and one rib segment) were harvested from three subjects. The ribs were loaded in the cranial–caudal direction, the ventral–dorsal direction and in torsion around the cervical rib axis. The force applied to and the displacement of the loading point on the rib were measured and used to determine the moment–angle responses. Characteristic average curves and boundary curves containing the dataset were developed. The torsion response presented a range of motion—defined as the change in the angle for an applied moment varying from −0.1 to 0.1 N m—of 16.9 ± 6.8° which is more than three times the range in cranial–caudal flexion and five times the range in ventral–dorsal flexion. Statistical tests showed a significant difference between these ranges of motion. Significant inter-subject variability was observed for the cranial–caudal flexion ( p < 0.05) while no intra-subject variability appeared. The characteristic moment–angle responses of the joints were well represented by third order polynomials ( R 2 > 0.9). This study expands and supplements the limited data available in the literature. Furthermore, it provides biomechanical data (closed-form moment–angle functions) that can be directly integrated into spine-ribcage models.

SU‐FF‐I‐164: Automated Suppression of Ribs in Digital PA Chest Images by Means of Image Processing

Purpose: Ribs in chest images have a negative effect on observer performance for detecting lung lesions. The purpose of this study was to develop a fully automated image processing technique for reducing the contrast of ribs by means of image processing and thereby to increase the sensitivity of lesion detection. Method and Materials: Digital chest radiography (ThoraScan, Delft Imaging Systems) provides sufficient large dynamic range and high bit depth to register accurately the entire range of radiation intensities in the latent PA chest image. This implies that visibility of lesions in the lungs should improve after suppression of ribs. The rib suppression technique incorporates four basic steps: lung field segmentation, global rib segmentation, rib contour detection and signal subtraction in rib regions. Ribs are suppressed using estimates of the pixel intensity in the rib structure and its adjacent background. The difference between these estimates is weighted and subtracted from the rib structure, the degree of suppression of the ribs can be adjusted by changing the weight. The result is optimized using model information of the rib. To provide a proof of concept, PA chest images of ten patients were included in a pilot study. Results: Ribs in PA digital chest radiographs of ten patients were automatically suppressed by means of image processing. The general appearance of lung tissue, vessels and lesions in the lung fields improved. Conclusion: An automated image‐processing technique for rib suppression has been developed. The impact of this technique on the sensitivity of detection of lung nodules in digital chest radiographs will be investigated in a future observer performance study.

TH‐C‐304A‐02: A Probabilistic Neural Network Using the Haralick Transform to Segment Ribs in Chest Digital Radiographs

Purpose: Segmenting ribs in chest radiographs is the first step toward a system of automated diagnosis in digital radiography (DR) of the lung. Methods: We use a probabilistic neural network (PNN) and selected components of the Haralick transform as a feature vector to train our neural network in this segmentation task. A Haralick transform composed of statistical components is employed as a feature vector where the relevance of each component to the particular task is determined using a simple scatter plot analysis. A training set is generated by randomly selecting pixels around which a 16 by 16 pixel ROI is constructed. This is done for rib and non‐rib regions. The Haralick transform is applied to this window as a feature vector characterizing the window and hence the region. Once the components from the scatter plot analysis are selected, the Haralick transform is applied. The method is automated in that each pixel is interrogated and classified by the PNN. Results: The PNN performs well with 50 training vectors each from rib and non‐rib areas. There are typically 7 relevant Haralick components after scatter plot analysis. We demonstrate the effectiveness of the method with images that show rib segmentation on two different patients using the same Haralick components and PNN. Conclusion: A probabilistic neural network and the Haralick transform have been shown to be effective methods for segmenting the ribs in digital radiographs of the lung. The next phase would consist of morphological operations to turn the extracted rib images into binary images, thereby allowing the ribs to be disregarded in computer assisted diagnosis of lung DRs.

Use of vascularized periosteum or bone to improve healing of segmental allografts after tumor resection: an ovine rib model.

Despite technical advances, nonunion or delayed union remains an important clinical problem when segmental allografts are used to repair diaphyseal defects after bone tumor resection. Using an ovine rib model, the authors studied whether the addition of a vascularized periosteum or bone flap improved healing compared with a segmental allograft alone. A 4-cm segment of rib was resected from four consecutive ribs of 15 sheep. Three different reconstructions were compared within the same sheep: allograft alone, allograft and vascularized periosteum, and allograft and vascularized bone. One defect was not reconstructed and served as a control. Five sheep were humanely killed at each of the following time points: 9, 12, and 15 weeks. The host-allograft junctions were analyzed using plain radiographs, micro-computed tomography, and histologic examination. Micro-computed tomographic analysis showed significant improvement with each reconstruction technique over time. Plain radiographs and histologic analyses demonstrated earlier bridging of the host-allograft junction when either vascularized periosteum or vascularized bone was used compared with allograft alone. Use of vascularized periosteum or bone may facilitate healing of the host-allograft junction after intercalary allograft reconstruction.

Late Aortic Injury: A Rare Complication of a Posterior Rib Fracture

Traumatic rib fractures are common and are often associated with a hemothorax or pneumothorax. Rib fractures can also be a marker of severe trauma, and aortic transection is a well-described cause of death, particularly after a deceleration injury. However, direct aortic laceration by a fractured rib segment is extremely rare. We describe the late presentation of such a case and discuss the possible mechanism of injury.

Osteomusculocutaneous flap for clavicular reconstruction: a case report

Sir, My interest was piqued by Yel et al. [1] with their fascinating article titled, “Osteomusculocutaneous Xap for clavicular reconstruction: a case report.” The authors reported a case of persistent clavicular nonunion after pathologic fracture because of necrotic Wbrosis due to radiation for breast cancer therapy. They managed it with compound riblatissimus dorsi osteomusculocutaneous Xap and a 4 cm segment of the sixth rib. Clavicle orientation is found to rotate from a primarily craniocaudal orientation at the sternum to a primarily anteroposterior orientation at the acromion. Although it appears almost straight when viewed from the front, when viewed from above, the clavicle appears as an S-shaped double curve that is concave ventrally on its outer half and convex ventrally on its medial half. In cases of total excision of clavicle, reconstructive surgery should be considered if shoulder function is decreased. But is diYcult to restore the normal shape of clavicle, by the use of bone interposition graft, because of its particular shape. However, an anatomic reconstruction may oVer normal function of the shoulder, prevent luxation of the clavicle and satisfy cosmetic demands. Total replacement of the clavicle with vascularised and osteotomised Wbula has been already reported once [2]. Three fragments of double osteotomised Wbula with appropriate angulations were plated with two titanium compression plates and resulted to a neoclavicle, with good results to be mentioned after 2 years of follow up. But no X-rays have been provided after the follow up to conWrm the anatomical restoration of the neoclavicle. Probably with this operative technique, the shape of clavicle is restored almost anatomically in this way. This suggestion became strong when a malunion of humerus fracture resulted in S-shape, was observed in our institution. Recently, a 30-year-old man was admitted to our hospital because of a malunion of proximal humerus. He was presented with his upper extremity internally rotated. Surprisingly, his olecranon was in the front side of his upper extremity. According to his history, he was sustained a fracture of proximal diaphysis of humerus before 25 years, after a traYc accident. Because of other fatal injuries such splenic rupture, Xail chest and lung contusions, the humerus fracture was misdiagnosed. Finally, his fracture was malunited with his humerus rotated about 180°. Clinical examination was revealed a humerus which was concave ventrally on its half and a normal shoulder. His X-ray showed an S-shaped humerus like the shape of clavicle. Immediately, we hypothesized that rotation instability may be responsible for an S-shape of a long bone. As a matter of fact rotation instability leads to scoliosis deformity also. In X-rays the normal thoracic or lumbar spine it appears straight when viewed from the front, but it appears as an S-shaped in scoliosis. It is well known that idiopathic scoliosis is a threedimensional deformity of the spine combining lateral curvature with vertebral body rotation [3]. The essential lesion lies in the sagittal plane in the nature of lordosis. It has been showed that the spinal deformity in pinealectomized chickens developed rotational lordoscoliosis similar to human idiopathic scoliosis [4]. In similar way after B. Saccomanni (&) Orthopaedic and Traumatologic Surgery, University of Chieti, Via dei Vestini, 66013 Chieti Scalo, Italy e-mail: bernasacco@yahoo.it

Near-fatal bleeding after transmyocardial ventricle lesion during removal of the pectus bar after the Nuss procedure

a rib segment to an intact portion of the same or adjacent ribs. Our patient’s injuries precluded other described techniques owing to the lack of intact structures to anchor stabilizing components. Our novel use of Nuss bars enabled us to create a viable superstructure to suspend the chest wall and allow full re-expansion of the lung. This technique will be useful in patients whose severity of injury precludes stabilization by previously described methods. We corresponded with Dr Donald Nuss for his thoughts. He wrote:

Primary chest wall lymphoma with no history of tuberculous pyothorax: Diagnosis and treatment

Primary chest wall neoplasm represents only 5% of chest wall neoplasm and among them primary chest wall lymphoma is uncommon. A 28-year-old man had no history of tuberculous pyothorax or artificial pneumothorax therapy but did have a 4-month history of dyspnea, fever, chills, and night sweats. On physical examination, a mass about 10 x 10 cm was noted on the anterior chest wall on the right side, and computed tomographic scan demonstrated that it originated from the pleural wall. A 42-year-old man was admitted with intermittent left hemithoracic pain from about 6 months before his visit. A 5 x 5-cm tender mass in the posterior wall of the left hemithorax was palpated. Computed tomography showed mild plural effusion and erosion in the posterior segment of the left ninth rib. Surgery was performed for histologic diagnosis. With the diagnosis of large B cell lymphoma, chemotherapy was prescribed for the first patient, and the patient has been in complete remission for more than 5 months. For the second patient, the left ninth rib along with the originated mass was completely resected and chemotherapy was prescribed. The patient has been in complete remission for more than 8 months. Treatment of primary chest wall lymphoma was not clear and various treatment strategies were considered. Remission of considerable duration in our patients leads us to suggest that surgery followed by adjuvant chemotherapy can provide a reasonable outcome in patients in whom the chest wall lymphoma is the only site of disease.