Congenital superior sternal cleft repair using our modified Sally technique: A case report

Modified surgical reconstruction technique for a rare isolated congenital sternal cleft: In a six -year-old child

We report the modified surgical reconstruction technique for correction for a large isolated congenital sternal cleft in 6 years old girl using a methyl methacrylate marlex mesh sandwich plate (MMS). The patient was referred to our tertiary care institution with a sizeable anterior chest wall bony defect. There was a large bulging under the skin due to protrusion of mediastinal viscera and visible cardiac pulsations with breathing. A chest x-ray and computed tomographic scan (CT) of the thorax was done to evaluate the bony defect. We reconstructed the sternal bony defect by our innovative technique using methyl methacrylate. The patient was discharged after three days for further follow up in outpatient. One year follow up patient is doing well with excellent results. Our technique is simple, cost-effective, and provides a perfect cosmetic effect for children's sternal large defects.

INTRODUCTION

Sternal clefts are rare congenital malformations that result from the defective embryologic fusion of paired mesodermal bands in the midline. This rare anomaly incidence is 1:100,000 cases per live births, which constitute 1% of all congenital chest wall deformities. The first Case of the sternal cleft was reported in 1740. The hereditary sternal gap is rare, and hence sporadic cases have been reported in the medical literature. Ravitch described that the first surgical correction was reported by Lannelongue et al., in 1988., But Burton published the first successful repair in 19474. An isolated sternal cleft is a rare entity and is classified into two categories' complete and incomplete sternal gap. Early repair is recommended; otherwise, surgical correction is challenging in children as the hypo plastic sternal edges cannot be approximated primarily, and this requires prosthetic, autologous grafts or some kind of parasternal chondroplasties.

CASE PRESENTATION

Since birth, a six-year-old girl was referred to our tertiary care center with a large central chest wall defect. She was a full-term normal delivery with no other congenital malformations. The defect was noticed at birth and became more evident as she grew up. In addition to cosmetic concern on coughing, there was bulging under the skin and visible cardiac pulsation. On examination, there was a large gap (7cm) in the midline of the chest with sternal adages well apart, moving independently.

DISCUSSION

The sternal cleft is a congenital anomaly with less than 0.15% and is more common in the female gender. Isolated sternal cleft without any other associated abnormalities is very rare. It has been reported as a part of defined syndromes like PENTALOGY OF CANTRELL, VACTREL, DANDY WALKER, and PHASE (Posterior fossa brain malformation, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormality).6 Embryo logically sternum originate from the somatic layer of lateral mesodermal plates as bilateral bands. They fuse in the midline by the 10th week to constitute a cartilaginous framework of manubrium, sternum, and xiphoid process. Failure of this fusion can lead to a partial or complete sternal cleft.7 Etiology of this disease is unknown; however, it has been linked with riboflavin or methyl-cobalamin deficiency, high alcohol intake during pregnancy.

CONCLUSION

in conclusion, our improvised reconstruction technique for large sternal cleft in children has several advantages. There is no need to do extensive chordotomies or using bone grafts. Less complicated procedure Provides more rigid frame for protection of thoracic structures and better chest wall stability. Hospital stay is minimal and is very cost-effective. The child's future growth is not affected as ribs and costal cartilages are left intact in this technique. There is no chance of displacement or excursion of the MMS plate. In female patients, this provides better cosmoses as there is no need to mobilize the pectoralis significant muscles flaps for coverage. The geometry of the rib cage is well preserved.

Reversed autogenous sternal plate flaps for treatment of sternal clefts: A novel technique

OBJECTIVE

A sternal cleft is an extremely rare congenital anomaly resulting from a failure of the fusion of the sternal bars. The condition can be classified as complete or incomplete, where there is an inferior or less commonly a superior attachment. We report our experience with a modified surgical technique using a reverse autogenous sternal plate flap to treat complete sternal clefts in children beyond the neonatal period without the need for any prosthetic material or disruption of the chest wall structure.

PATIENTS AND METHODS

The technique was performed on three patients beyond the neonatal period at the age of 2, 4 and 12years. Two patients were female and one was a male. All cases were performed by a single surgeon. Parents were consented for the new technique. Institutional review board (IRB) approval was obtained.

RESULTS

Recovery in all children was uncomplicated, and they were discharged home after 4, 4 and 5days respectively. There were no morbidities among all 3 patients. Review at 4 and 12weeks revealed complete wound healing and a well-united sternum. All remain asymptomatic on a median follow-up period of 22months.

CONCLUSIONS

Our new technique in repairing complete sternal clefts was easy, reproducible and generated satisfactory results on a reasonable follow up period. Most importantly we avoided the use of prosthetic material and any disruption to the chest wall structure in a subgroup of older patients.