Chest wall reconstruction with autologas rib grafts in dogs and report of a clinic case

Anterior Chest Wall Reconstruction After Separation of Thoraco-Omphalopagus Conjoined Twins With Cadaveric Rib Grafts and Omental Flap

BACKGROUND

Anterior chest wall defects have a wide range of etiologies in the pediatric population, ranging from infection, tumor, and trauma to congenital diseases. The reconstructive goals include restoring skeletal stability, obliterating dead space, preserving cardiopulmonary mechanics, and protecting vital underlying mediastinal organs. Although various reconstructive methods have been described in the literature, selecting the optimal method is challenging for the growing pediatric skeleton. Here, we report a case of previously thoraco-omphalopagus twins who underwent successful separation and reconstruction and presented for definitive anterior chest wall reconstruction.

METHODS

A pair of previously thoraco-omphalopagus conjoined twins underwent definitive anterior chest wall defect reconstruction using cadaveric ribs and omental flap. Twin A received 2 cadaveric ribs, whereas twin B had a much larger sternal defect that required 3 cadaveric ribs combined with an omental flap for soft tissue chest coverage. Both twins were followed up for 8 months.

RESULTS

Twin A's postoperative course was uneventful, and she was discharged on postoperative day 6. Twin B's course was complicated, and she was discharged on supported ventilation on postoperative day 10. At 8 months postoperatively, both twins healed well, and chest radiographs confirmed the stability of the chest reconstructions. The rib grafts in the twin with a tracheostomy were not mobile, and the patient had a solid sternum with adequate pulmonary expansion. The construct initially did not facilitate pulmonary functioning, but after a healing process, it eventually allowed for the twin with the tracheostomy who required pulmonary assistance to no longer need this device.

CONCLUSIONS

Cryopreserved cadaveric ribs and omental flaps offer safe and reliable reconstructive methods to successfully reconstruct congenital anterior chest wall skeletal defects in the growing pediatric population. The involvement of multidisciplinary team care is key to optimizing the outcomes.

Sternal tumor resection and reconstruction with titanium mesh: a preliminary study

OBJECTIVE

To explore the clinical efficacy and complications of treating sternal tumors by resection and titanium mesh thoracic reconstruction.

METHODS

This retrospective analysis of eight patients with sternal tumors treated in the Department of Orthopedic Surgery at the First Affiliated Hospital of Zhengzhou University from January 2008 to June 2012 included five men and three women aged 37-66 years (mean, 50.4 years). The histological diagnoses were chondrosarcoma (two cases), osteosarcoma (one), malignant fibrous histiocytoma (two), eosinophilic granuloma (one) and sternal metastasis from breast cancer (two). The tumors were invading the manubrium sterni (three cases), manubrium sterni and body (three) and sternal body (two). All patients underwent needle or incisional biopsy prior to sternal tumor resection and titanium mesh thoracic reconstruction.

RESULTS

All patients were followed for 9 months to 4 years. There were no intraoperative complications or operative or postoperative deaths. One patient developed a deep wound hematoma 1 week postoperatively; incisional drainage and debridement resulting in healing within 2 weeks. There was no loosening or exsertion of the titanium mesh and no patients developed respiratory complications or thoracic deformity. One patient with malignant fibrous histiocytoma died of lung metastases 9 months postoperatively, another with malignant fibrous histiocytoma died of liver metastases 14 months postoperatively; the remaining patients survived without tumor recurrence.

CONCLUSION

Titanium mesh chest reconstruction after sternal tumor resection has the advantages of simplifying the procedure, achieving a good shape and having few complications. Titanium mesh is an ideal material for reconstruction of the sternum.

Allogenic sternal transplant after sternectomy for metastasis of ovarian carcinoma

Sternal metastasis from ovarian carcinoma is extremely rare. We report a case of a young woman in whom a single metastasis at the level of the upper portion of the sternum developed. Surgical excision of the sternum was performed with replacement by a sternal allograft stabilized by titanium plates and transosseous high-tension sutures. With this simple and reproducible technique, we obtained a stable and dynamic reconstruction of the sternoclavicular joints and shoulder girdle. The use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible.

Aneurysmal bone cyst of sternum

Aneurysmal bone cyst (ABC) is a benign but locally destructive lesion of the bone characterized by the presence of spongy or multi-loculated cystic tissue filled with blood. It accounts for 2.5% of all bone tumors. An ABC may involve almost any bone, but the most frequent sites are long tubular bones and vertebrae. The sternum is a rare location for an ABC. Here we present a case with sternal ABC, discuss the clinical manifestations and treatment, and review the literature. Radical wide resection of primary sternal tumors and reconstruction with appropriately rigid prosthetic material are necessary to avoid chest wall instability and minimize local recurrence.

Use of latissimus dorsi and abdominal external oblique muscle for reconstruction of a thoracic wall defect in a cat with feline osteochondromatosis

A 4-year-old, male castrated European shorthair cat was presented with a firm mass palpable on the right caudal rib cage. Lateral and ventrodorsal radiographs of the thorax revealed a 4x3x2cm large, expansile and radiodense mass originating from the distal part of the 13th rib. After removal of the tumour, which was histopathologically confirmed as feline osteochondromatosis, the diaphragm, omentum, external abdominal oblique and latissimus dorsi muscles were used to reconstruct the defect. Feline osteochondromatosis is induced by retroviruses, eg, feline leukaemia virus, for which the cat tested positive. The tumour was removed for palliative reasons, because such tumours have the tendency to transform into osteosarcomas. Six months after the surgical excision the cat showed no clinical signs of reoccurrence.

Use of a latissimus dorsi myocutaneous flap for one-stage reconstruction of the thoracic wall after en bloc resection of primary rib chondrosarcoma in five dogs

OBJECTIVE

To describe a thoracic wall reconstructive technique using a latissimus dorsi myocutaneous flap after en bloc resection of primary rib chondrosarcoma and report outcome in 5 dogs.

STUDY DESIGN

Retrospective study.

ANIMALS

Dogs (n=5) with primary rib chondrosarcoma.

METHODS

Medical records (2003-2005) were reviewed for signalment, staging investigations, surgical findings, complications, and outcomes. Owners and veterinary surgeons were contacted for outcome information.

RESULTS

A latissimus dorsi myocutaneous flap provided an air-tight thoracic wall closure after chondrosarcoma resection. Paradoxical respiratory movement of the flap occurred; however, from physical examination and blood gas analysis (2 dogs), ventilation was adequate. All flaps survived, 1 had superficial skin necrosis distally and 2 had minor wound dehiscence. One dog without tumor-free margins died of tumor-related disease 56 days after surgery. Tumor recurrence did not occur in 4 dogs with tumor-free margins. One dog was euthanatized 10 months after surgery for unrelated disease; 3 dogs were alive at writing (median follow-up: 20 months; range, 18-27 months) and all had a satisfactory functional and cosmetic outcome.

CONCLUSIONS

Reconstruction of ventral thoracic wall defects using a latissimus dorsi myocutaneous flap yields a functional, cosmetic outcome.

CLINICAL RELEVANCE

A latissimus dorsi myocutaneous flap can be used as a successful 1-stage reconstructive technique for ventral thoracic wall defects.

Comparison of mersilene mesh-methyl metacrylate sandwich and polytetrafluoroethylene grafts for chest wall reconstruction

We report the outcomes of patients who underwent reconstruction with Mersilene mesh-methyl methacrylate (MM-MM) sandwich and polytetrafluoroethylene (PTFE) grafts after a large chest wall resection. Between June 1990 and September 2001, 59 consecutive patients (37 men, 22 women; mean age, 48.1 +/- 11.8 years; range 22-74 years) underwent large chest wall resection (greater than 5 cm diameter) and reconstruction with prosthetic material in our department. Twenty-one patients (33%) underwent reconstruction with a PTFE graft (group 2) between 1990 and 1994, and 38 patients (67%) underwent reconstruction with an MM-MM sandwich graft (group 1) between 1994 and 2001. Operative morbidity ratios were 5.2% (2/38) in group 1 and 24% (5/21) in group 2 (p = .036). The paradoxical respiration ratio was significantly higher (p = .018) in group 2 (5/21: 24%) than it was in group 1 (1/38: 2.6%). The operative mortality ratio was 4.5% (1/21) in group 2 and 0% in group 1. Mean hospital stay was 10.6 days (range 5-21 days) in group 1 and 13.3 days (range 7-36 days) in group 2 (p = .015). The MM-MM graft is inexpensive and easy to apply, provides better cosmetic options, and offers minimal morbidity. We therefore recommend that the MM-MM sandwich graft be used rather than the PTFE graft for large defects of the anterolateral chest wall and sternum where successful prevention of paradoxical respiration is required.

Reconstruction de la paroi thoracique antérieure par lambeau fibulaire libre et latissimus dorsi

In order to preserve the respiratory function of the thorax the reconstruction must be immediate and must answer currently to principles of repair very codified. We reported a case of thoracic reconstruction by an association of flaps, free fibular and pedicled of the latismus dorsi, after a resection of a shrewd tumour of the thoracic partition. This reconstruction has permitted the contribution of a musculocutaneous cover of good quality and the contribution of a skeletal support satisfying at a time. The association of flaps can be considered like one of the solutions for the reconstruction of the big losses of substance of full thickness of the thoracic partition requiring a restoration of the thoracic skeleton.

Full-thickness chest wall reconstruction using autologous tissue grafts after resection of recurrent desmoid tumor

We report the case of a 62-year-old woman with a recurrent desmoid tumor of the chest wall who successfully underwent a full-thickness chest wall resection as well as skeletal and soft tissue reconstruction. In chest wall reconstruction, we used various kinds of autologous tissue grafts, i.e. rib, fascia lata and the transverse rectus abdominis myocutaneous flap. Judging from the reconstructed wall's strength, shape and flexibility, as well as wound healing, it is possible to conclude that this combined procedure is feasible because benefits of the procedure outweigh the disadvantage of additional operations for harvests.

Pulmonary resection with chest wall removal and reconstruction for invasive pulmonary mucormycosis during antileukemia chemotherapy

A 54-year-old woman undergoing chemotherapy for acute myeloid leukemia developed invasive pulmonary mucormycosis in the right upper lobe at the neutropenic nadir. Amphotericin B therapy became ineffective after an abscess formed in the affected lung, and insufficient infection control compelled us to interrupt chemotherapy. The lesion was suspected of invading the anterior chest wall. After right upper lobectomy combined with the anterior chest wall resection, the chest wall defect was reconstructed using autologous free rib grafts. Successful control of the fungal infection by resection enabled us to restart chemotherapy with concomitant use of Amphotericin B. In selected cases of leukemia-associated pulmonary mucormycosis refractory to Amphotericin B therapy, aggressive surgical intervention may facilitate anti-leukemia chemotherapy and prolong survival.