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PubMed2005

Sternum lifting technique for thoracoscopic internal thoracic artery harvest.

We employed the Laparolift and Laparofan (Origin Medsystems Inc., CA, USA) and developed a sternum lifting technique to create a sufficient intra-pleural space between the heart and the sternum in which the left internal thoracic artery (ITA) in situ graft could be thoracoscopically mobilized. Between June and December 2004, this technique was applied to 12 consecutive patients (eight men, four women, aged 68.5+/-9.6 years) undergoing minimally invasive coronary artery bypass grafting via a left mini-thoracotomy. The Laparofan, connected to the arm of the lift machine (Laparolift), was introduced through a subxyphoidal entry and opened beneath the sternum. The sternum was elevated by about 5 cm until a sufficient working space was created under the sternum. With left hemipulmonary collapse, the left ITA was thoracoscopically taken down through the axillary ports. There was no procedural conversion to direct harvesting. The mean thoracoscopic harvesting time was 34.5+/-7.7 min. There was no mortality and no instrument-related morbidities. Patency of each ITA graft was angiographically confirmed. In conclusion, despite the limited experience, the present sternum elevation technique using the Laparolift system is a viable method for increasing the intra-pleural working space beneath the sternum during thoracoscopic ITA harvesting.

Aged↗
PubMed2001

[Fractures of the sternum].

PURPOSE OF THE STUDY: Assessment of the authors' group of patients with a fracture of sternum and comparison with available literary findings. MATERIAL AND METHODS: In a group of 188 patients with a blunt injury of chest who were hospitalised in the Faculty Hospital in Olomouc in the period of 1996-1999 there were 7 cases with the diagnosis of the fracture of sternum. In this group of patients we observed the cause of injury, occurrence of associated injuries, the potential of diagnostic methods, method of treatment and duration of hospitalization. RESULTS: Mostly they were patients with an isolated fracture of the sternum or with an associated injury requiring only a short-term hospitalization. One patient with a rupture of v. azygos died from the sequelae of other multiple injuries. Another patient sustained a fracture of sternum together with a massive hemothorax and hemomediastinum. On the basis of circulation stability this patient was treated conservatively. For details see the case report. Six patients were subsequently transferred to out-patient department and are now without complaints. DISCUSSION: The most beneficial examination for the diagnosis of the fracture of sternum remains lateral radiograph of the chest. With regard to potential injuries of mediastinal organs it is necessary to perform ap radiograph of the chest and ECG, in indicated cases also CT of the chest, angiography and echocardiography, if need be. In patients treated for a fracture of sternum the duration of hospitalization and mortality is determined by the severity of the associated injuries. Surgical treatment is considered rarely in fractures with a greater dislocation or in injuries or mediastinal organs. CONCLUSION: The incidence of the fracture of sternum has recently increased. Isolated injuries of the chest do not pose any diagnostic or therapeutic problem. Of much greater severity are associated injuries of lungs and mediastinal organs which require a precise diagnosis and careful observation of the patient.

Adult↗
PubMed2002

Sternum screw: analysis of a novel approach to the closure of the chest after surgery.

BACKGROUND: To show the benefits of using a novel approach to closure of the median sternotomy through a mechanical model and mechanical testing. Simple cannulated screws are placed on either side of the sternotomy. Conventional stainless steel wire is passed through the cannula of each screw and the sternotomy is closed in the usual manner. METHODS: Hertzian contact analysis was used to estimate the stress between the wire and the sternum. Mechanical testing was used to compare using wire on its own with a sternum screw plus wire. Ten samples of balsa wood (sternum substitute) had wire placed through a hole in them, while a further ten samples were fitted with a cannulated screw and had wire passed through the screw cannula. The wire was connected to a materials testing machine, which applied tension to the wire until the wire or screw cut through the wood. RESULTS: The analysis showed that the mean stress between the wire and the sternum decreases with increasing wire diameter. At low diameters of wire the stress in the sternum can be comparable to the failure stress of bone. Using a cannulated screw reduces the stresses in the sternum. The mechanical testing showed that the wire cut through the wood at a mean load of 104 N, whereas the sternum screw cut through the wood at a mean load of 209 N (p = 0.007, Mann-Whitney Test). CONCLUSIONS: Closing a median sternotomy with cannulated screws plus wire should reduce the occurrence of sternal dehiscence.

Biomechanical Phenomena↗
PubMed1995

Anatomic study of the collateral blood supply of the sternum.

A microdissection study was carried out on ten injected, cleared human sternal specimens. Three types of vessel were identified that have the potential to carry blood to the sternum after mobilization of the internal thoracic artery (ITA): (1) branches of the ITA that supply both the sternum and the pectoralis major ("sternal/perforating branches"), (2) branches of the ITA that supply both the sternum and an adjoining intercostal space ("sternal/intercostal branches"), and (3) posterior intercostal arteries that do not anastomose with an ITA branch but continue past the ITA to reach the sternum. All three types of vessel were found more frequently in the proximal than in the distal half of the sternum. For sternal/perforating and sternal/intercostal vessels to function as collaterals after ITA bypass grafting, their short common trunks of origin must remain intact. The data support the recommendation that the branches of the ITA be ligated as close as possible to the ITA itself to preserve collateral blood flow to the sternum.

Aged↗
PubMed1985

Mechanical coupling between the ribs and sternum in the dog.

We measured the axial (cranio-caudal) displacements of the sternum and the second and seventh bony ribs using linear displacement transducers in five supine anesthetized dogs during passive inflation and deflation, during quiet breathing and static inspiratory efforts before and after bilateral phrenicotomy, and during tetanic stimulation of either the sternocleidomastoids or the sternal fibers of the rectus abdominis. Quiet inspiration before and after phrenicotomy was always associated with a caudal displacement of the sternum and a cranial displacement of the seventh rib; the second rib, however, was either motionless or also showed an inspiratory caudal displacement. During static inspiratory efforts, the second rib was always moving in concert with the sternum in the caudal direction, while the seventh rib, in particular after phrenicotomy, usually moved in the cranial direction. Finally, for any given axial (cranial or caudal) displacement of the sternum, stimulation of the sternocleidomastoid or rectus abdominis muscles invariably caused the second rib to move disproportionately more than the seventh. These results indicate that the upper ribs are more tightly linked to the sternum than the lower ribs. This presumably results from the fact that the costal cartilages increase in length from above downwards, and it implies that the upper portion of the rib cage behaves more as a unit with the sternum than the lower portion.

Animals↗
PubMed2004

Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray.

OBJECTIVE: Fractured ribs and sternum are frequent complications of thoracic compression during CPR in adults. This study was conducted to determine whether findings of plain chest radiography (CXR) correlate with post-mortem findings in patients who underwent cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest. METHODS: CXR findings and autopsy results of CPR-related chest injuries comprising rib and sternum fractures were compared prospectively in 19 patients. RESULTS: Fractures were diagnosed in nine of 19 patients by means of radiology and in 18 of 19 patients by autopsy (rib fractures in 6/19 versus 17/19, P=0.002; sternum fractures in 5/19 versus in 9/19, P=0.227. The total number of isolated bone fractures detected by CXR was 18 (12 rib and six sternum fractures) and by autopsy 92 (83 rib and nine sternum fractures). The majority of rib fractures was located in the anterior part of the thoracic cage. Sternum fractures predominantly occurred in the lower third. Eight of 19 patients received either thrombolytic or antithrombotic treatment during CPR but no major bleeding complication associated with CPR was detected by autopsy. CONCLUSIONS: The findings of this study indicate that fractures associated with CPR are underreported in conventional radiographic investigations. No major bleeding complications related to CPR-associated fractures was detected.

Adult↗
PubMed2003

Preliminary evaluation of the Sternum Screw: a novel method for improved sternal closure to prevent dehiscence.

Sternal dehiscence is a relatively rare but serious complication of sternal closure with an unacceptable mortality and morbidity rate. The 6 mm cannulated Sternum Screws are a novel approach that aims to prevent dehiscence. The screws are placed on either side of the sternotomy and wire threaded through the cannula and closed customarily. The Sternum Screws make the bone non-penetrable at the same time retaining the familiarity of conventional stainless steel wire. This novel technique was tested in sheep sterna to compare its efficacy to conventional wire closure. Using tensile testing in a testing machine, randomised controlled closures of the Sternum Screws and No. 5 stainless steel wires were evaluated until system failure. Seventeen matched pairs were tested. The Sternum Screw closure was on average 36% stronger, 284+/-43 N (mean+/-SD) compared to conventional wire closure alone, 215+/-38 N (mean+/-SD) [p<0.0001 by t-test]. System failure in 82% of Sternum Screw closures, however, was due to wire breakage or untwisting rather than the screw itself. In all these cases the screw remained intact in bone. 71% of conventional wire closures failed by dehiscing through the sterna. The mean forces required for wire dehiscence and wire failure in the Sternum Screws may be achieved in vivo during large coughs. The study shows there is merit in further evaluating the approach as a method of preventing dehiscence. It also highlights the use of alternative wiring techniques increase the tensile strength of the closure yet retain the familiarity and versatility of conventional wire.

Animals↗
PubMed1996

Metallic dissolution of a civil war bullet embedded in a sternum.

The contemporary trend of converting departments of anatomy into departments of cell biology has brought with it the task of examining archive collections and storage facilities to figure out how to best utilize the available space. During one such inspection at the University of Louisville School of Medicine, a human sternum containing a dull metal projectile was uncovered. The projectile was easy to characterize as a bullet that had been deeply embedded in the bone. Less clear, however, were the circumstances detailing how the bullet had become lodged in the sternum, or how long the sternum might have been in storage at the University of Louisville. Radiographs of the sternum revealed a halo of surrounding density that dissipated in intensity from the margins of the bullet. Our initial hypothesis was that lead had been leached from the bullet into the bone matrix. To better assess what in fact contributed to this density, the sternum and the bullet were analyzed by energy-dispersive spectroscopy (EDS) to determine their elemental composition. That the bullet was composed of lead and aluminum was not surprising, but the extent to which the presence and dissolution of the bullet had affected the composition of the bony sternum was not entirely expected. The contribution of metal ions from the bullet to the inorganic matrix of bone was most notable for aluminum but nearly negligible for lead. This finding confirmed that bone affinity for metals is dependent upon the metal and supports previous reports that have suggested that lead is released from bone as soluble blood product during bony remodeling, whereas aluminum results in a significant elevation of bone density.

Aluminum↗
PubMed1999

Comparison of autogenous cancellous bone grafts obtained from the sternum and proximal portion of the tibia of llamas.

OBJECTIVE: To describe the anatomy of the sternum in llamas, define the surgical approach to the sternum for collection of cancellous bone graft tissue, and compare the histologic appearance of graft tissue obtained from the sternum with that obtained from the proximal portion of the tibia. DESIGN: Prospective study. ANIMALS: 12 llamas, 3 to 19 years old, that had been submitted for necropsy. PROCEDURE: Radiographs were taken of the sternum and left tibia of the llamas. Measurements of the sternum were determined from the radiographs and adjusted for magnification. Sternebrae volumes were estimated from these measurements. Anatomic dissections to the center of the fourth sternebra and the proximal portion of the tibia were made, and a surgical approach to the sternum was developed. Cancellous graft tissue was obtained from each site and submitted for histologic evaluation. RESULTS: Sternebrae 3, 4, and 5 were significantly larger in volume than the other sternebrae. The ventral aspect of the fourth sternebra was readily accessed for removal of graft tissue by making a 6-cm-long ventral midline incision centered 17 cm craniad to the xipnoid. Mean soft tissue thickness overlying the ventral aspect of the fourth sternebra was 3.1 cm. More tissue was obtained from the sternal (mean, 9.11 g) than from the tibial (mean, 5.16 g) sites. Sternal graft tissue consisted of trabecular bone spicules with predominantly hematopoietic marrow, whereas tibial tissue consisted of trabecular bone spicules with only fatty marrow. CONCLUSIONS AND CLINICAL RELEVANCE: The fourth sternebra in llamas is readily accessible for obtaining autogenous cancellous bone graft tissue that consists of predominantly hematopoietic marrow.

Animals↗
PubMed2006

Morphometric analysis of the sternum.

Sternum has a great clinical significance, considering that median sternotomy is the most common surgical approach used in cardiac surgery. The aim of this study is to standardize the sternum according to size, shape and sex and to obtain ranges of the "standard sternum". The study was done on 55 male and 35 female sterna of the average age of 65. Complex morphometric analysis of breadth, length and thickness of the sterna were performed on sternal segments which were defined by costal notches. Morphometric analysis shows that the general sternum structure in the females and in the males is equal. The standard dimensions of female and male sternum were determined. Standardization according to shape suggests that there is one standard sternum shape present in more than 2/3 of analysed samples of both sexes.

Cardiac Surgical Procedures↗
PubMed1974

[Vascularization of the human adult sternum (author's transl)].

The study of the vascularization of the sternum allows to individualise the vascular pedicles, the anterior and posterior peripheral sternal networks and the intrasternal vascularization. 1. The numerous vascular pedicles of the sternum all come from the internal mammary arteries. The postero-superior and postero-inferior sternal arteries of one simple intercostal space or of contiguous spaces are anastomosed by systems of latero-sternal, retroarticular and retro-sternal arches. From these arches come vessels which go directly to the sternum or which form the posterior peripheral sternal network. The anterior sternal branches of perforating arteries form arches or go directly to the anterior peripheral sternal network or to the sternum. The veins are less anastomosed than the arteries and therefore their arches are less distinct. 2. The anterior and posterior peripheral sternal networks are especially developed with respect to the lower half of the body of the sternum at the level of the 4th and 5th intercostal spaces. The posterior network is more developed than the anterior network. The arteries often have a spiral course, their anastomoses occur with their contralateral and homolateral homologues. The veins, which are of larger calibre than the arteries, design a denser and more irregular network. 3. The intra-skeletal vascularization, tributary of the peripheral networks, arches and branches of the internal mammary vessels, includes a network of the compact bone and a medullary network. The network of the compact bone, situated in one plane, is composed of polyhedral elongated meshes, according to the large axe of the sternum. The medullary network may be divided into a sub-cortical and a centro-medullary part. The sub-cortical part is composed of a peripheral zone and a more central zone. The totality of the intramedullary network includes a few fine arteries, an interadipocytary network, which is very developed and is variable in form. It also include sinuses of increasing order connected into the venous system, into the network of the compact bone, or into the large trans-cortical veins, which are drained by the peripheral sternal networks or by the collateral veins or the internal mammary system.

Adolescent↗
PubMed1982

[X-ray findings of the sternum after sternotomy (author's transl)].

X-ray examination of the sternum after sternotomy supplies proof of rupture of a suture, of dehiscence of the sternum, malpositioning of the wire ligature, of the cutting-through of the fixation wire by the bone, of the fracture, pseudoarthrosis and inflammation. Fractures can be located in the manubrium sterni, the body of the sternum, the xiphoid process and in one of the two parts of the sternum. Pseudoarthroses can be seen in the manubrium, in the body of the sternum or as longitudinal pseudoarthroses. Pseudoarthroses were found only in conjunction with inflammatory chances. Signs pointing to an osteomyelitis of the sternum can be very discreet. This applies to both the reactive scleroses and to osteolyses. In individual cases the examination of a fistula system allows identification of a connection to the bone or to the ligature material. Retrosternal abscesses can be differentiated in the computer tomogram from dissections after bolus injection. Diagnosis by exclusion requires tomography in two planes with complicated blurs. In such cases the diagnostic reliability is probably far superior to the reliability achieved by plain roentgenography and with longitudinal blurring.

Abscess↗
PubMed1993

Contribution to the study of the development and ossification of human sternum.

We have studied the development of sternum in man. Complete microscopic series of sections through thorax of human embryos and fetuses from the second and third months of gestation served as the research material. Preparations were stained by Alcian blue and Mayer's haematoxyline, counterstained by eosine. We also had a set of macroscopic preparations of sterna and adjacent parts of ribs from fetuses of the fifth and sixth months of gestation. These specimens were stained by Alcian blue and by Alizarine and subsequently cleared by glycerine method. We have found that sternum develops by a fusion of sternal bars. Sternal bars develop from anterior bent parts of ribs, lying one over another like tiles. The newly formed sternum has different proportions in comparison to its definitive state. In all the cases its manubrium is wider and bigger, its xiphoid process is longer, in almost all the cases doubled or at least bifurcated. The sternocostal junctions are provided with interzones with the exception of the first rib. Its primordium continues into sternum without any border. Clavicle is connected with sternal anlage without any visible border and this interzone quickly develops as the primordia of the sternoclavicular articulation and the disc. In the medial part, there is a cartilaginous model which ossifies very early--as the first bone of the body. In young embryos from the end of the second month of gestation the clavicle and sternum show very different structures. Ossification of the sternum begins in the fifth month by developing a large number of very small centers of ossification which are not yet detectable by X-ray or CT.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed1977

[Regularities and differences in the structure of the circulatory bed of the sternum].

The investigation has been carried out in 95 preparations of the anterior chest wall of corpses of humans of either sex aged from newborns to 90. It has been established that the blood supply of all the layers of sternum is brought about by the anterior and medial branches of the internal sternum artery forming subperiosteal plexuses on its anterior and posterior surfaces. The posterior plexus is better developed. Its loops are of less size and denser per a square surface unit. Three types of blood supply of the manubrium sterni posterior surface have been distinguished (right-side, balanced and left-side types) as well as two variations of blood supply of the sternum body (in the first variant two sternal branches approach the sternum at the level of every intercostal space, in the second variant--only one does). The outflow of the venous blood from the sternum is brought about into the anterior and posterior venous subperiosteal plexuses and then via one of the three anatomical variations into the internal thoracic veins. The subperiosteal network of the sternum in newborns and infants is of segmentary character and is formed in relation with developing ossification nuclei. With age, in the process of fusion of the ossification nuclei the subperiosteal network looses its segmentary character and acquires a common total character.

Adolescent↗
PubMed1999

A hypomorphic myogenin allele reveals distinct myogenin expression levels required for viability, skeletal muscle development, and sternum formation.

The myogenic basic helix-loop-helix transcription factor myogenin plays an essential role in the differentiation of skeletal muscle and, secondarily, in rib and sternum formation during mouse development. However, virtually nothing is known about the quantitative requirements for myogenin in these processes. Here, we describe the generation of mice carrying a hypomorphic allele of myogenin, which expresses myogenin transcripts at approximately one-fourth the level of the wild-type myogenin allele. The hypomorphic allele in combination with wild-type and myogenin-null alleles was used to create an allelic series. Embryos representing the complete range of genotypes from homozygous wild type to homozygous null were analyzed for their viability, ability to form normal ribs and sternum, and extent of skeletal muscle differentiation. Embryos carrying the hypomorphic myogenin allele over a wild-type allele were normal. In embryos bearing homozygous hypomorphic alleles, the sternum developed normally and extensive skeletal muscle differentiation occurred. However, muscle hypoplasia and reduced muscle-specific gene expression were apparent in these embryos, and the mice were not viable as neonates. When the hypomorphic allele was placed over a myogenin-null allele, the resulting embryos had sternum defects resembling homozygous myogenin-null embryos, and there was severe muscle hypoplasia. Our results demonstrate that skeletal muscle formation is highly sensitive to the absolute levels of myogenin and that correct sternum formation, skeletal muscle differentiation, and viability each require distinct threshold levels of myogenin.

Alleles↗
PubMed1998

[Resection and reconstruction of sternum].

In case of sternal resection, it is necessary to preserve bone material indispensable for the stability of the anterior chest wall and air tightness of the thoracic cavity, and the support of the chest wall integrity must be restored by some means. Various techniques have been applied to the reconstruction of the chest wall following resection. During the last 10 years, we have performed reconstructive operation for 6 cases of the chest wall following resection of the sternum in recurrent cases of breast cancer or invaded case of primary breast cancer. In these patients, the chest wall was reconstructed using a rib-latissimus dorsi osteomyocutaneolus flap or a latissimus dorsi myocutaneous flap. The sternum was totally resected in 3 cases, and in all 3 cases, reconstructed using a rib-latissimus dorsi osteomyocutaneous flap. Although postoperative pulmonary function decreased, all cases could be relieved from endotracheal intubation within 17 hours after operation, and had no problems in activities of daily living or occurrence of chest flailing or paradoxical movement of the chest. An artificial material (expanded polytetrafluoroethlene patch) was used in only one patient for the reconstruction of the osseous thorax, but this case developed infection during postoperative chemotherapy. After this experience, we used only biological materials for the reconstruction of the chest wall and postoperatively performed radiotherapy and/or chemotherapy on all cases. We have observed no flap infection or detachment since then. One characteristic of using the latissimus dorsi myocutaneous flap is that it is easily elevated and rarely causes serious postoperative esthetic or functional problems. The flap is also easily utilized to reinforce the osseous thorax because ribs immediately below the latissimus dorsi muscle are readily mobilized as a pedicle graft. Reconstruction of the chest wall following resection of the sternum, described in this report, allowed us to perform radiotherapy and/or chemotherapy without serious postoperative complications on the cases relapsing after treatment of breast cancer. The 2-year survival rate is 50% and one of these cases survived up to 10 years after resection of the sternum. Thus we prefer to perform resection of the sternum for sternal recurrence of breast cancer if there are no metastatic lesions in other organs.

Adult↗
PubMed1985

Effect of resection of the sternum and manubrium in conjunction with muscle transposition on pulmonary function.

We recorded the changes in pulmonary function that occurred after removal of the sternum and manubrium and repair by pectoralis major muscle transposition in six patients. Of these patients, three had osteomyelitis of the manubrium and sternum, two had osteosarcoma of the sternum, and one had osteomyelitis and radionecrosis of the manubrium and sternum. Body plethysmography and the rebreathing, hypercapnic ventilatory response test with inductive plethysmographic recordings of chest-wall motion were performed preoperatively and postoperatively. Preoperatively, four of the six patients had evidence of mild to moderate chest-wall restriction. Pulmonary function was normal in the other two patients. Postoperatively, total lung capacity was unchanged but the vital capacity decreased 11.5% in the overall group. Static compliance, retractive force, and the steady-state diffusing capacity for carbon monoxide decreased modestly but significantly postoperatively. The expiratory flow rates and maximal voluntary ventilation remained unchanged. Preoperatively, the slope of the hypercapnic ventilatory response was less than that predicted. Postoperatively, the slope did not change. In three patients, however, increased dependence on the abdomen for breathing suggested a dynamic restriction of rib-cage motion. On the basis of our findings, we conclude that surgical removal of the sternum and manubrium in conjunction with muscle flap repair is a well-tolerated procedure. Any postoperative changes in pulmonary function are minor.

Adolescent↗
PubMed1995

Eurysternum (extra-wide sternum)--a rarely recognized developmental anomaly. Scintigraphic appearances.

A rarely recognized extra-wide sternum was demonstrated by Tc-99m methylene diphosphonate bone scans in two adult patients. One patient was a 53-year-old man with prostate cancer who had no sternal symptoms or known sternal deformity. The second patient was a 41-year-old man with carcinoma of the lung whose extra-wide sternum was associated with a pectus excavatum deformity involving the lower half of the mesosternum (corpus sternum). A proper name for this developmental abnormality, "eurysternum" (eury-Greek word meaning broad; wide), is suggested. Two other patients, one with another type of wide sternum and another with a mesosternal foramen (fenestra sternii) deformity are also described. Related embryology and developmental anatomy of the sternum are reviewed.

Adult↗