Osteosynthetic thoracic stabilization after complete resection of the sternum.

We present a case of a 66-year-old diabetic patient with chronic non-healing sternum after CABG operation. After four attempts of sternum refixation within 2 years, the need of bone debridement resulted in a nearly complete loss of sternum. Finally, a mesh graft and a pectoralis muscle flap were used to bridge the sternal space. Despite good wound healing, the thoracic instability led to intolerable chest pain persisting over the next years. In this case report, we describe the successful thoracic stabilization by using transverse plate fixation, which resulted in perfect thoracic stabilization and immediate cessation of pain.     

Successful reconstruction of sternum with a scapular autograft segment: 5-year follow-up

Complete loss of the sternum after osteomyelitis leads to chest wall instability and decreases respiratory mechanics. Thus, surgical management with prosthetic devices or various flap coverage procedures is required to restore anterior chest wall stability. We report on a new technique of an osteocutaneous flap from the scapula providing thoracic stability and protective coverage of mediastinal organs, and additionally allowing removal of osteosynthesis material. A 5-year follow-up demonstrates excellent durability and outcome.     

Aspergillus osteomyelitis of the sternum after thoracoplasty

The case of a 69-year-old man with osteomyelitis of the sternum caused by Aspergillus is reported. The patient had undergone a thoracoplasty eighteen months before for left empyema. At operation, the lower fourth of the sternum with some bilateral costal cartilages was resected, and the resultant dead space was covered with a rectus abdominis muscle flap. The diagnosis as Aspergillus osteomyelitis of the sternum was confirmed by culture of resected material. The cause of sternal osteomyelitis was assumed to be direct spread from an infection of costal cartilages left at thoracoplasty. He was discharged on the 31st postoperative day after complete wound healing.     

Surgical treatment of chronic osteomyelitis of the sternum and the ribs]

Transsternal approach is commonly used in majority of operations in heart surgery. In 0.5-5.9% of patients after median sternotomy osteomyelitis of the sternum and the ribs develops. The authors set forth their experience in surgical treatment of 182 such patients. In 97% of them total resection of the sternum was combined with simultaneous resection of costal cartilages which were involved in pyogenous inflammatory process. Costal cartilages were resected during subtotal resection of the sternum in 95% of cases and ribs--in 25%. Limited resection of the sternum was used only in patients with suppuration in the area of sutures in the sternum. Radical one-stage resection of the pyogenous site at the anterior thoracic wall was carried out in 62 patients. In 120 patients in poor condition and who previously underwent an opening of the abscess, staged surgery (2 or more operations) was performed. The authors suggest that in patients with cardio-pulmonary and hepato-renal insufficiency it is advisable to repair the defect, developed after resection of the thoracic wall, by split and perforated cutaneous flap. Muscular flap (32 patients) and greater omentum flap (30 patients) with vascular pedicles or local tissues (28 patients) were used for plastics of the thoracic wall defects. In 98 patients for the closure of the defect autodermoplasty with free split perforated cutaneous flap was used, otherwise the wound of the thoracic wall in them recovered by secondary intention type. 168 (92%) patients have recovered, 4 patients developed recurrence of osteomyelitis, 10 patients died. The authors suggest that the treatment of such serious patients should be carried out in specialized departments which have experience in thoracic, purulent and plastic surgery.     

Vascularized rib support for chest wall reconstruction using Gore-Tex dual mesh after wide sternochondral resection

Only a few reports describe chest wall reconstruction after sternal resection using Gore-Tex dual mesh, and very few reports describe the use of a vascularized rib to support the thoracic cage. We present a case of a breast cancer patient who underwent anterior chest wall resection for recurrent sternal cancer. Her sternoclavicular joints bilaterally and lower sternum were divided using an electric saw. The bony chest wall was reconstructed using Gore-Tex dual mesh, and a vascularized rib was used to bridge the space between the clavicular heads to support the thoracic cage. The patient's postoperative course was uneventful, without complications, such as paradoxical respiration or pneumonia.     

Chest wall reconstruction using a free rectus abdominis myocutaneous flap in a case of recurrence after bilateral breast cancer surgery

A 64 years old woman with anterior chest wall recurrence after bilateral mastectomy for breast cancer was treated by the resection of chest wall in full thickness involving the whole sternum and the anterior part of ribs except the first rib. The thoracic cage was reconstructed using a free rectus abdominis myocutaneous flap which was placed over Marlex mesh covering the defect of chest wall. By means of surgical microscope, inferior epigastric artery and vein of the graft were anastomosed with internal thoracic artery and vein at the neck, respectively. Postoperative course was uneventful and the patient is alive and well for one year after the surgery. A free myocutaneous flap method provides enough volume of soft tissue for coverage of a large defect and chest wall stability.     

Solitary eosinophilic granuloma of sternum

Primary bone tumors of the chest wall are uncommon, although a wide variety of both benign and malignant tumors arise within the chest wall. Among those tumors, sternal tumors are rare and usually malignant. We report an extremely rare case of eosinophilic granuloma developed in the sternum in a 30-year-old woman. She presented anterior chest pain and somewhat tender mass over the sternum. Chest roentgenogram, computed tomography scanning of the thorax, and total body bone scintigraphy revealed an isolated lytic lesion in the corpus sterni. A tru-cut biopsy of the mass exhibited the typical histologic appearance of eosinophilic granuloma. The solitary lesion was removed completely surgically. This rare condition should be kept in mind in differential diagnosis of sternal lesions.     

Transverse plate fixation of sternum: a new sternal-sparing technique

We report 2 cases of vacuum-assisted closure therapy and thoracic reconstruction using new sternum titatium plates in patients with deep sternal wound infection after median sternotomy. The specific advantage of this new approach is anatomical reduction of the sternum that prevents paradoxical movement and severe anterior chest instability, and improves postoperative outcome.     

The anatomy of the ribs and the sternum and their relationship to chest wall structure and function

As with all parts of the body, the anatomy and physiology of the chest wall are intimately intertwined. To carry out the unique functions performed by the chest wall, the anatomic structures are formed precisely for maximal efficiency. This article focuses on the unique structural characteristics in the internal thoracic diameters. It discusses the specific anatomy of the ribs and costal cartilages, along with the sternum. How these parts interrelate through joints is described also. Finally, it describes the muscles that cause the motion in the chest wall.     

Operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate

Surgical stabilization of flail chest is a controversial operation, but recent data has shown that selected patients benefit from it. We describe a simple and practical method of operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate anchored to the ribs and sternum. The methylmethacrylate–mesh complex is inexpensive, can be extracted electively as soon as full thoracic stability is achieved, and can be used to stabilize extended chest wall injuries.     

'Extended deep inferior epigastric artery flaps' for reconstruction after excision of chondrosarcoma sternum.

We describe a case of chondrosarcoma of the sternum requiring wide full thickness chest wall excision thereby creating a difficult defect for reconstruction. A mesh was used for support and two extended deep inferior epigastric artery fasciocutaneous flaps were mobilised medially into the defect.     

Giant cell tumour of the sternum

A patient with histopathologically benign but clinically malignant giant cell tumour of the sternum underwent total strnectomy. The chest wall defect was repaired by mobilising pectoralis major muscles on either side without any respiratory embarrassment.     

Staged cleft sternum repair using dermal allograft and synthetic mesh

Cleft sternum is a rare congenital chest deformity that develops during the first trimester. Failure of the process of midline mesenchymal strip fusion leads to absence of the sternum, resulting in cleft formation. Multiple surgical approaches have been described in the closure of sternal clefts. An optimal surgical approach is still debatable. We describe 2 cases of complete sternal clefting treated with staging of the repair. Dermal allograft and synthetic mesh along with myofasciocutaneous flaps are used a bridging method to future definitive treatment. Most patients will require secondary cardiothoracic procedures for underlying cardiac conditions, and disruption of any primary repair is compromised on reentry into the chest. Staging this procedure avoids this potential problem. Also, concerns regarding chest wall constriction and cardiopulmonary compromise are minimized. Once the child has matured, definitive treatment can be pursued with more abundant autologous donor tissue. Our approach is safe with minimal complications and is well tolerated by the patients.     

Complete chest wall reconstruction after en bloc excisions with Gore-Tex/Marlex/Flap sandwich. A retrospective study of 14 cases

To assess the results of surgical resection and chest wall reconstruction we reviewed our experience with the complete chest wall reconstruction after en bloc excisions according to an original algorithm based on the location of the thoracic defect. The 14 reconstructions were performed by the senior author. We found 5 central, 6 lateral and 3 borders locations. In the central locations with a total resection of the sternum the reconstruction was realized by Gore-tex's mesh in depth, metal hooks (staples) and Marlex's mesh under a musculocutaneous flap of coverage. In case of lateral location the reconstruction was realized by Gore-tex's mesh covered with a musculocutaneous flap, the borders locations were reconstructed by Marlex's mesh and flap of coverage. The histological diagnoses were: one desmoid tumor, eight sarcomas, a recurrence of hepatocarcinoma and four recurrences of breast cancer. The superficial coverage performed by latissimus dorsis flap 12 for cases and rectus abdominis flap for two cases. All the patients were able to produce a spontaneous breath after surgery. Two deaths at distance and an infection were to regret. On the whole the algorithm of reconstruction according to the location of the defect allows a simplification of the indications.     

Sternal resection and chest wall reconstruction for primitive neuroectodermal tumor of the sternum

Primitive neuroectodermal tumor of the sternum is rare. A 59-year-old woman referred to our department with anterior chest pain and a tumor in the sternum. The patient was diagnosed as primitive neuroectodermal tumor of the sternum by core biopsy of the lesion. She received 2 cycles of preoperative chemotherapy with vincristine, doxorubicin, cyclophosphamide, ifosfamide, etoposide. She underwent a total sternectomy with resection of adjacent bilateral costal cartilages and sternal ends of the clavicles. The skeletal defect of chest wall was reconstructed by polypropylene mesh-resin sandwich. The myocutaneus defect was reconstructed by the pedicled latissimus dorsi myocutaneus flap and the bilateral breast flaps. The postoperative course was uneventful and adjuvant radiotherapy was started 6 weeks after the operation. She died of distant metastases 3 months after the operation, although this patient was free from local recurrence.     

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.     

Cleft sternum and sternal foramen

Cleft sternum is a rare congenital defect of the anterior chest wall and is the result of a failed midline fusion of the sternum. Depending on the degree of separation, there are complete and incomplete forms. Its clinical significance is that it leaves the heart and great vessels unprotected. Association with craniofacial hemangiomas and omphalocele is common. Prenatal diagnosis by ultrasonography is possible. Surgical correction should be performed during the neonatal period when the direct suturing of the sternal halves is possible and the thorax can accommodate the thoracic viscera. At an older age, surgical repair is feasible, but it may require additional measures, such as sliding chondrotomies of the adjacent costal cartilages and notching of the sternal bars, to facilitate the approximation. Lung herniation at the base of the neck should be corrected by uniting the cervical muscles. The first postoperative day is the most critical because of acute reduction of the mediastinal space. Long-term results are satisfactory. Sternal foramen is a congenital oval defect at the lower third of the sternum that is asymptomatic and could be detected by CT scanning. The awareness of the anomaly is important in acupuncture practice because of the danger of heart damage.     

Chronic expanding hematoma in sternum resected 5 years after median sternotomy

Chronic expanding hematomas occur at various locations in the body; however, their occurrence in the sternum has not been reported yet. We report a patient with chronic expanding hematoma in the sternum 5 years after undergoing a median sternotomy for cardiac surgery. Although preoperative biopsy specimens did not lead to a definitive diagnosis, we could not rule out the possibility of a malignant tumor because of the expanding and infiltrative behavior of the hematoma. We performed a sternectomy and reconstructed the chest wall using artificial materials.     

Fractures of the sternum associated with spinal injury

Twelve cases of sternal injury associated with spinal fractures have been reviewed. The sternum is regularly buckled or fractured in patients with high thoracic spinal fractures. Our review suggests that sternal injuries may also be associated with spinal fractures outside this region, and with types of fracture other than crushing of vertebral bodies. Injury to the sternum, when due to indirect violence, is almost always associated with a severe spinal column injury. A displaced fracture of the thoracic spine, with or without an associated sternal fracture, can produce significant widening of the mediastinal shadow on a chest radiograph. This is caused by a paravertebral haematoma, and can be difficult to differentiate from widening due to an aortic rupture.     

Giant cell tumor of the sternum

A primary giant cell tumor (GCT) originating from the sternum is extremely rare. We report a case of a GCT originating from the sternum in a 45-year-old man who was referred to us for a mass in the anterior chest wall that had been growing slowly. Computed tomography revealed a soft tissue mass involving a large osteolytic and destructive lesion of the sternum body. Subtotal sternectomy and reconstruction with methylmethacrylate were performed. The tumor was 8.5 × 4.5 × 2.5?cm, and the histopathological examination confirmed GCT. Radical wide resection of primary sternum tumors and reconstruction with an appropriately rigid prosthetic material are necessary to minimize local recurrence.