A new method of sternal approximation

After sternotomy for a cardiac operation in adults, closure of the sternum is accomplished with five or six wire sutures with twisting of the wire ends. This method may not chieve rigid fixation of the sternum, and the bulky twisted wires may cause skin pain or actual perforation. We have developed a new method of approximating the split sides of the sternum using a new instrument, the Wolvek approximator. With this method rigid fixation is obtained and the ends of the wires are fixed by a small crimped metal plate. This method has been used clinically with success.     

Marlex mesh support for the correction of very severe and recurrent pectus excavatum

A method for the correction of very severe and recurrent pectus excavatum is presented. The technique consists of mobilization of the sternum, transverse osteotomy, parasternal resection of the costal cartilages (modified Ravitch procedure), followed by placement of Marlex mesh behind the sternum and suturing the edge of the Marlex mesh to the peripheral stump of the resected ribs. This method has been used with good results in 6 patients, 2 of them with recurrent deformities.     

Surgical repair of pectus excavatum

Pectus excavatum is the most common chest deformity. Children with severe deformities suffer physical complaints such as frequent respiratory infections and decreased endurance. Patients with even mild deformities may complain of physical and psychological symptoms after puberty. In most patients, cardiac and respiratory function deteriorates, meaning that surgical correction is important for alleviation of symptoms and improving cardiopulmonary function and quality of life. The methods of surgical repair remain controversial. The traditional method, first described by Ravitch, comprises resection of deformed cartilages and correction of the sternum by wedge osteotomy in the upper sternal cortex. Ravitch’s methods have been modified using autologous or exogenous materials to fix the lower sternum. Nuss reported a novel method in which neither an anterior wound nor the cutting of cartilage or sternum is required; instead, a convex metal bar is placed behind the sternum. We have reported sternocostal elevation, in which a section of costal cartilage is resected, and all of the cartilage stumps are resutured to the sternum. The secured ribs pull the sternum bilaterally, such that the resultant force causes the sternum to rise anteriorly. Because most pectus excavatum patients are young and maintain an acceptable quality of life preoperatively, we believe that the morbidity rate is one of the most important factors in selecting the method for corrective surgery. Repair can be performed safely through the use of skilled techniques and a deep understanding of the anatomy and physiology of the thorax.     

An improved method for repair of pectus chest deformities

An improved method for repair of pectus excavatum is presented. The method may also be used for repair of asymmetrical funnel chest and pectus carinatum.The principles of repair are to (1) remove the deformed costal cartilages, (2) eliminate the flare of the lower ribs, (3) place the sternum in its normal anatomical position, and (4) reestablish costosternal union.Deformed cartilages are excised subperichondrially. Removal of the costal margin is carried to the apex of the defect. The margin is then made continuous by approximating the free ends in the midline. This latter maneuver eliminates the costal flare. The remaining ribs are brought into apposition with the sternum. The sternum is immediately stable in the normal anatomical position. No extrinsic devices are used.     

Simplified technique for closure of median sternotomy incision: the use of bone stapler

A new technique with the bone stapler (Staplizer) was applied in 11 patients undergoing open-heart surgery for closure of a median sternotomy incision. The staplers were used for fixation of the sternum following partial trans-sternal fixation with two wires. The method was quick and easy to perform, and effective in establishing firm and permanent approximation of the sternum. There were no instances of dehiscence among all the patients with stapler closure. We therefore recommend this technique in median sternotomy closure except for patients with the osteoporotic or elastic sternum.     

Peristernal closure of median sternotomy using stainless steel bands.

Peristernal closure of median sternotomy incisions with interrupted stainless steel bands has proved to be a rapid and safe method for achieving solid internal fixation in approximation of the sternum. The method is particularly useful for obese patients undergoing sternotomy. There have been no instances of wound dehiscence using this technique, and several other advantages over standard forms of sternal closure are apparent. The method is a useful addition to the cardiac surgeon's armamentarium.     

Repair of Pectus Excavatum by Sternal Eversion

Pectus excavatum was repaired by the sternal eversion (turnover) technique in 26 patients over a 7-year period. Vascular supply to the sternal graft was maintained by preservation of one internal mammary vascular pedicle. Good results were obtained in 21 (81%) patients followed for periods ranging from 2 to 76 months (mean, 32 months) postoperatively. Four patients (15%) had fair results; 2 patients with Marfan's syndrome had partial recurrence, as did 1 patient with skin necrosis and 1 with hypertrophic scar. One patient (4%) had a poor early result due to wound infection and distal sternal necrosis requiring reoperation. Other complications were minor: superficial wound seroma in 2 patients and pneumothorax in 1.The sternal eversion technique for repair of pectus excavatum utilizes the concave shape of the sternum when turned over to create a cosmetically acceptable convex anterior chest wall contour. Judicious tailoring of the costal cartilages and shaping of the anterior sternum corrects asymmetrical deformities. The chest wall is very stable after repair. Since no prosthetic struts or pins are used, a second operation for removal is avoided. Preservation of the vascular supply to the sternum should allow normal growth of the anterior chest wall. The results have been sufficiently encouraging for us to recommend sternal eversion as the primary method for repair of pectus excavatum.     

Titanium Transverse Plate Fixation: A New Solution for Old Sternal Problems

Objective: To evaluate our initial results with the titanium transverse plate fixation system of the sternum in four patients.

Methods: Two patients with late dehiscence and persistent instability of the sternum after cardiac surgery were treated with refixation by titanium transverse plates and screws. Two patients were treated with the same refixation method after pre-treatment with debridement, antibiotic therapy and vacuum-assisted closure therapy for extensive mediastinitis.

Results: All four patients healed without complications. The mean postoperative length of stay was 17,3 days (range 744). The instability and/or pain disappeared in all patients. The postoperative imaging showed good positioning of the osteosynthesis material. There was no re-infection in patients with mediastinitis.

Conclusions: The titanium transverse plate fixation system is a very promising adjunct to the armamentarium of the car-dio-thoracic surgeon for treatment of sternal problems, including dehiscence and fractures, even when mediastinitis is involved. It offers more stability compared to simple rewiring, without the need for extensive retrosternal dissection.     

Management of a floating sternum after repair of pectus excavatum

PURPOSE: The aim of this study was to examine the authors' experience with patients who have floating sternum after correction of pectus excavatum via the classical Ravitch procedure. A floating sternum is defined as a sternum in which the only attachment to the chest wall is its superior (cranial) border, and in which the body is secured only by the manubrium and whatever lateral and inferior fibrous bands are present. Typically, a floating sternum is caused by either extensive resection of the costal cartilages and perichondrium during correction of pectus excavatum or failure of proper regrowth of these cartilages. METHODS: The authors retrospectively assessed the charts of all patients diagnosed with a floating sternum noting age at original correction of pectus excavatum, time from original correction of pectus excavatum to diagnosis of floating sternum, age at correction of floating sternum, complaints before stabilization of the sternum, methods of repair, and postoperative complications. RESULTS: Between July 1993 and June 1999, floating sternum was diagnosed in 7 patients. The mean age of patients who underwent operative correction of a floating sternum was 28.9 years (range, 16 to 42 years). The mean time interval between original correction of pectus excavatum, or "redo," and diagnosis of a floating sternum was 9.9 years (range, 2 to 20 years). Complaints before correction of the floating sternum included sternal pain and instability, exercise intolerance, and difficulty breathing. Operative repair consisted of mobilizing the lateral and inferior edges of the sternum, detaching the fibrous perichondrium, performing anterior sternal osteotomies, and finally supporting the sternum with substernal Adkins struts. All 7 patients had successful stabilization of the sternum. Two of 7 patients underwent 2 procedures to successfully stabilize the sternum. One patient has Adkins struts still in place because of hematopoetic malignancy. Six of 7 patients are now without symptoms. CONCLUSIONS: A floating sternum is a morbid phenomenon that may manifest many years after the original procedure. It can cause significant sternal pain, chest wall instability, and respiratory dysfunction, which are the hallmark indications for correction. Repair of a floating sternum can be accomplished successfully.     

Mersilene ribbon closure of the median sternotomy: an improvement over wire closure

With the increased utilization of median sternotomy in thoracic surgery, some difficulties have arisen with closure of the sternum. This article presents a simple, easy-to-perform method of sternal closure utilizing reinforcement of the sternal halves with a material that is less likely to cut through the sternum and that is readily available.     

Experience of sternal secondary closure by means of a titanium fixation system after transverse thoracosternotomy

Sternal dehiscence is a common complication after transverse thoracosternotomy in patients undergoing bilateral sequential lung transplantation (BSLT). These patients can be treated with conservative therapy, but severe dehiscence requires surgical reapproximation and secondary closure of the sternum. Seventy-one cases of patients who underwent BSLT between January 2007 and May 2009 were reviewed retrospectively. Out of 71 patients, the sternum was intact in two cases due to the use of bilateral anterolateral thoracotomy, and a clamshell incision had been utilized in 69 patients. Four patients (6.8%) presented with persistent chest pain with severe sternal dehiscence diagnosed by chest X-ray and/or chest computed tomography, and underwent sternal reapproximation using the Synthes Titanium Sternal Fixation System for longitudinal sternal plating. All four patients had successful sternal realignment and resolution of their preoperative clinical symptoms. No perioperative or postoperative complications were observed. The Synthes Titanium Sternal Fixation System is an appropriate and effective method for internal fixation of the sternum when used for symptomatic severe sternal dehiscence after sequential BSLT via transverse thoracosternotomy.     

Sternal turnover operation for pectus excavatum

Fifteen cases of sternal turnover performed over a three-year period are reported. The overall results with the method appear to be excellent. There is no question that the sternum, the cartilages, and the intercostal muscles remain viable and are suitable to be reimplanted as a free autograft if this type of repair is indicated. The incidence of wound complications has not been prohibitive, and no complication has been major. There have been no deaths in the series. The plane of the manubrium, an acute hump on the sternum, and asymmetry constitute limiting factors in the cosmetic results.     

Postponed closure of the sternum after operations on the heart with extracorporeal circulation

Data on postponed closure of the sternum in 3 patients who were operated on with extracorporeal circulation are discussed. Various clinical and technical aspects of the applied method are considered. On the basis of their personal experience and the literature data, the authors discuss the causes of the development of acute heart dilatation in operations with extracorporeal circulation and, with due regard for this, substantiate the indications for the use of the method. Postponed closure of the sternum is a promising method of treatment of critical hemodynamic disorders which occur at the stage of closure of the sternotomy and are characterized by the picture of cardiac tamponade.     

Surgical correction of pectus excavatum using a retrosternal bar.

Pectus excavatum is a progressive congenital deformity for which surgical correction is an established procedure. The method of correction using a stainless steel retrosternal bar to maintain the sternum elevated is, in our experience, the most successful procedure. Successful surgical correction usually requires resection of all deformed costal cartilages with transverse osteotomy of the anterior table of the sternum and internal fixation using a bar anterior to the rib cage but behind the sternum. In the last 13 years 118 patients with this deformity have been evaluated and 72 patients have been surgically corrected by the described procedure. Of these 72 patients, 65 (90 percent) have had excellent or good cosmetic and functional results. The best results were obtained when the child was operated on between the ages of 6 and 10 years, the poorest results in those operated on under the age of 3 or over the age of 20. For a satisfactory result the bar must be left in for at least six months; the best results were obtained in those patients in whom the bar was left in for at least one year. No serious complications have followed the use of this technique.     

Surgical Treatment of Primary Sternal Osteomyelitis

Four patients with primary sternal osteomyelitis are described. Pseudomonas aeruginosa was the infective organism. Three of the 4 were heroin addicts. Limited surgical resection with preservation of the posterior periosteum is recommended for an infected sternum. Postoperative antibiotic therapy for a period of six weeks is also recommended. Preservation of the posterior sternal periosteum rather than conventional radical excision is important for maintaining physical stability and avoiding chest wall deformity in this group of patients.     

Fractured sternum with flail chest and posttraumatic pulmonary insufficiency syndrome. Report of 4 patients

The case histories of 4 patients who sustained sternal fractures with flail chest and pulmonary insufficiency are reported. Prompt open reduction and stabilization of the fractured sternum and continuous monitoring of cardiopulmonary function are necessary to prevent or control posttraumatic pulmonary insufficiency syndrome, which is the major cause of death in these patients.     

Ultrasound diagnosis of sternum fractures

AIM: With the present study we wanted to examine the value of ultrasonography in the diagnosis of fractures of the sternum. METHOD: Included in this study were 11 patients with pain in the sternal region and suspected fracture of this area according to case history and clinical examination. We exclusively used a 7.5 MHZ linear scanner. RESULTS: In all 11 cases the fracture was free of doubts diagnosed using ultrasound. A fragment dislocation could be visualized in 10 cases and 1 case showed a fissure of the sternum. The standard lateral X-ray as our reference method confirmed the sonographical diagnosis in all cases. CONCLUSIONS: The diagnostical value of ultrasonography of the sternum is at least as high as that of standard lateral X-ray. When a hypoechoic area over the sternum together with a hematoma, a disruption of the cortical bone or a step in the bony outline as a sign for fragment dislocation are found, sternal fracture is the definite diagnosis. Ultrasonography is quickly feasible, non-invasive and gives sufficient information in these cases without side effects.     

Surgical repair of pectus carinatum

Pectus carinatum represents a variety of protrusion deformities of the anterior chest wall. Although various non-operative methods of treatment have been employed, surgery has been widely accepted as the only effective method for the correction of pectus carinatum. We evaluate our 14 year single center experience of pectus carinatum correction on 111 patients using a uniform technique of internal stabilization employing stainless steel struts. Operative correction required double bilateral chondrotomy parasternally and at points of transition to normal ribs, followed by detorsion of the sternum, retrosternal mobilization and correction of the everted sternum as well as of the everted and inverted ribs. The mobilized sternum after incomplete wedge osteotomy was finally stabilized by one transternal and two bilateral parasternal metal struts. The corrections were completed with successful repair in 109 patients (98.2%). Major recurrences in 2 patients (1.8%) were corrected while mild recurrence were observed in 3 patients (2.7%).     

Complications of ascending aortic intraaortic balloon pump cannulation

Choice of a route of cannulation for intraaortic balloon counterpulsation during cardiopulmonary bypass is related to accessibility. In those patients in whom it is impossible to pass the intraaortic balloon pump (IABP) into the common femoral artery, ascending aortic cannulation is a rapid and direct method of insertion. Eight patients are described in whom ascending aortic IABP cannulation was undertaken to enable weaning from cardiopulmonary bypass after cardiac surgical procedures. The following problems were encountered: graft infection, aberrant cannulation of the left subclavian artery, left coronary artery embolism, and inability to close the sternum due to mechanical tamponade. A technique is described for insertion of the IABP using a polytetrafluoroethylene (Impra) graft and closed-chest decannulation. Although considerable morbidity and mortality are associated with ascending aortic cannulation, it is simple, fast, and effective, and should be considered for all patients requiring postoperative IABP support in whom peripheral vascular disease makes access difficult.     

Omentoplasty in surgical treatment of osteomyelitis of the ribs and sternum

Seven-year experience in the treatment of 21 patients with chronic osteomyelitis of the ribs and sternum is summarized. Great omentum was used as plastic and disinfecting material in combination with laser radiation. Indications, techniques, short- and long-term results are presented. There were no recurrences of purulent process in the bones. Omentoplasty is the method of choice in surgical treatment of purulent lesions of costal cartilage and sternum.