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Chest Wall Reconstruction
and Rib Fixation
Daniel L Miller MD
Chief, General Thoracic Surgery
Emory University Healthcare
The Kamal A Mansour Professor of Surgery
Emory University School of Medicine
Atlanta, Georgia USA
Chest Wall Resection/Reconstruction
• Multidisciplinary approach – Individualize patient
– Thoracic skeleton
– Soft tissue
– Critical care
• Etiological factors – Tumor
• Primary
• Metastasis
• Recurrent
– Radiation
– Trauma
– Infection
Chest Wall Reconstruction
1. Pleural cavity
2. Skeletal support
3. Soft tissue coverage
4. Postoperative critical care
Chest Wall Reconstruction
• Pleural cavity
– Pleural drainage
• air tight
– Muscle flap transposition
– Omentum transfer
– Pneumoperitoneum
– Thoracoplasty
– Eloesser flap
– Diaphragm reconstruction
Chest Wall Reconstruction
• Skeletal support – Fascia lata
– Bone (Rib graft)
– Teflon
– Silicone
– Mesh • PTFE
• Prolene
• Marlex
• Vicryl
– Methyl methacrylate sandwich
– Struts – PLA and titanium
– Bovine pericardium (Veritas)
– Alloderm
Chest Wall Reconstruction
Thoracic Skeleton
• Defects four contiguous ribs or greater
than 5 centimeters (The Rule)
– Chest wall stabilization (paradoxical motion)
– Protect vital organs
• May not need to reconstruct larger defects
if previous radiation therapy (Exception)
• Posterior defects are well tolerated
– Posterior ribs 1 – 3 (4) – Hinge point
– Scapula protection (Exception)
Osteogenic Sarcoma of Chest Wall
Neoadjuvant Chemotherapy
Margins of Resection (>4 cm)
Chest Wall Reconstruction
Polypropylene vs PTFE Mesh
• Operator dependent
• Polypropylene more
difficult to stretch
without wrinkles
• PTFE is watertight,
easier to handle
• Mayo Clinic
experience showed
little difference *
J Thorac Cardiovasc Surg 1999
Angiosarcoma Wide Resection
Sternum and Costal Cartilages
Radiation-induced Angiosarcoma Sternum
Sternal Reconstruction
Anterior Chest Wall Reconstruction
Methyl Methacrylate / Mesh Sandwich
• Prevention of
paradoxical
respiration
• Improved chest
contour
• Treatment of choice
for large skeletal
defects in many
institutions
Multiple Reconstruction Products PTFE and Methyl Methacrylate Sandwich
Chest Wall Reconstruction
Methyl Methacrylate / Mesh Sandwich
• Non-randomized study comparing methyl
methacrylate and PTFE
Methyl
methacrylate PTFE
Morbidity 5.2% (2/38) 24% (5/21)
Paradoxical
respiration 2.6% (1/38) 24% (5/21)
Journal Invest Surg 2006
Bovine Pericardium
Bovine Pericardium
Acellular Dermal Matrix
Acellular Dermal Matrix
• Potential use in contaminated fields
• Experimental data shows greater implant-
defect interface strength than PTFE at 4
weeks *
• Little long term clinical data
– Tensile strength
– Lung herniation
– Paradoxical chest wall motion
* Plast Reconstr Surg 2007
Chest Wall Reconstruction:
Soft Tissue Reconstruction – Muscle flaps
Chest Wall Reconstruction:
Soft Tissue Reconstruction
• Pectoralis major
• Latissimus dorsi
• Rectus abdominis
• Omentum
• Serratus anterior
• Free flaps: rectus abdominis, latissimus
• Thoracoepigastric skin flaps
Pedicled flaps
Bilateral Pectoralis Major Flaps
Recurrent Sarcoma Chest Wall
Acellular Dermal Matrix
Plastic Reconstr Surg 2004
Acellular Dermal Matrix
Latissimus Flap Coverage
Forequarter Amputation Chest Wall and Arm Removal
1..
Methyl Methacrylate Reconstruction
1..
Deltocervical Tissue Flap
1..
Infected Chest Wall Radiation Necrosis
Recurrent Cancer
Soft Tissue infection
Osteomyelitis
Radiation-induced Angiosarcoma Sternum
Titanium Struts Reconstruction
Radiation-induced Angiosarcoma Sternum
Bovine Pericardium (Veritas)
Radiation-induced Angiosarcoma Sternum
Postoperative CXR
Chest Wall Reconstruction
Poly Lactic Acid Bovine Pericardium
Sternal Reconstruction
Sternal Reconstruction
Sternal Reconstruction
Rib Defect Reconstruction
Rib Defect Reconstruction
BioBridge (PDS)
Rib Defect Reconstruction
Flail Chest
• Thoracic Trauma is seen in 20% of all trauma
• TT is cause of death in 25% of trauma cases
• Over 50% of the TT is rib fractures
• 1/13 pts (8%) have a flail chest
• Definition: More than 2 continuous rib fractures
at two separate sites
– Pulmonary Contusion
– Hemopneumthorax
– Associated injuries
Flail Chest
• Paradoxical motion (External)
• Pulmonary contusion
• Severe pleurtic pain
• Decreased tidal volume
• Alveoli collapse
• Arteriovenous shunting
• Hypoxemia
• Respiratory insufficiency
Flail Chest
Treatment
• Pain control – Narcotics, NSAIDs, Intercostal blocks, Epidural
catheter
• Aggressive physiotherapy (FOB)
• Careful fluid administration
• Pulmonary support (Internal stabilization)
– Intubation
– BIPAP
Flail Chest
Treatment
• Chest wall stability
• External stability (historical)
• Rib fixation (Limited size 8 – 12 mm, Thin
cortex, Continued movement)
– K wires (intramedullary)
– Anterior metal plating
– Locking systems (metal)
– Absorbable plates
Flail Chest Indications
• Flail chest
– Failure to wean
– Paradoxical motion weaning
– No pulmonary contusion
• Reduction of pain and disability
– Painful movable rib
– Failure of narcotics/epidural
– Fracture movement worsens pain
– Minimal associated injuries (ISS)
• Chest wall deformity
– Loss of chest wall integrity (crush injury)
• Non-Union rib fracture (> 2 months)
• Other thoracic surgery required
79 yo W fell 5 days ago (PD)
Presented to ER with SOB and CP
CT Scan – Displaced Rib Fracture
CT Scan – Displaced Rib Fracture
and Hemothorax
CT Scan - Hemothorax
CT Scan – Pulmonary Contusion
Repair Rib Fracture
Rib Loc System
S/P Rib Fracture Repair
Rib Loc times 2
Drainage Hemothorax (500cc)
Sternal Plating
Primary Sternal Plating
• Rigid plate fixation in 45 high risk patients
• Matched control group of 207 patients
• Mediastinal infection
– Control group 14.8%
– Rigid fixation group 0%
Eur J of Card Thor Surgery 2004
CW Reconstruction and Rib Fixation
• Thoracic skeleton reconstruction
– Small defects no reconstruction or mesh
– Large defects MMS, PTFE or TT struts
• Soft tissue reconstruction
– Small defects: latissimus dorsi or pectoralis
– Large defects: rectus abdominis, possible free flap
• Location and etiology is most important
• New chest wall product stabilization are
promising
Summary
• Keys to success in these complex cases:
– Total resection of the disease process
– Reconstruction of chest wall integrity
– Soft tissue coverage
• Team of physicians well versed in:
– Chest wall resection and reconstruction
• Prosthetic materials
– Free or pedicle flaps
– Critical care of the patient
Conclusions
• Chest wall reconstruction and rib fixation is
both safe and effective
• Each patient should be individualized
– Review old operative reports
– Review previous treatments regiments
– Life expectancy
– Quality of life
• Earlier treatment in warranted
• Team approach is mandatory