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Resection of the clavicular head and clavicular-manubrial junction is required in cases of chronic osteomyelitis or tumor. This article describes a technique for soft tissue coverage in an infected or irradiated area after resection using a split pectoralis major rotational muscle flap.
Transmanubrial osteomuscular sparing approach (TMA) has been recently proposed for the treatment of apical chest tumor to allow a safer subclavian artery control with a less invasive procedure for the patient. The present technique combines the antero-lateral muscle-sparing thoracotomy with TMA for lung cancer patients in whom extended resection of cervico-thoracic structures as well as anatomic lung resection and radical lymph nodes dissection are required.
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The sternal cleft is a rare congenital anomaly resulting from a fusion failure of the sternum, generally observed at birth and asymptomatic. Surgery is indicated to protect the heart and major vessels from trauma, to improve respiratory dynamics, and for aesthetic reasons. We observed 2 neonates for a superior and medial thoracic mass. The defect involved the upper two thirds of the sternum. The surgical operation for both patients consisted in the primary closure of the defect.
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99mTechnetium-MDP bone scintigrams in 11 patients with ankylosing spondylitis were reviewed. Increased activity in sacroiliac joints was present in five of 11 cases, all of whom had symptoms of less than 5 years duration. Patients with longstanding disease had normal or low sacroiliac joint activity. In the spine, appearances included diffuse symmetrical, unifocal or multifocal asymmetrical increased uptake involving the costovertebral, costotransverse and facet joints as well as the spinous processes. In advanced disease with extensive ankylosis, the lumbar spine was featureless on scintigraphy, except for focal increased activity at the site of previous fracture in one patient. Of six available views of the sternum, increased uptake was present in five at the manubriosternal joint and five at the sternoclavicular joints. Increased peripheral uptake was mainly in the hips and knees in advanced cases. Plain radiographic changes correlated poorly with scintigraphic changes, scintigraphy detecting considerably more lesions than radiography. Awareness of the scintigraphic appearances of ankylosing spondylitis may lead to diagnosis before the development of radiographic changes and avoid confusion with other pathology. Clinical indications for bone scintigraphy in ankylosing spondylitis are suggested.
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The thirty-eighth case of bronchogenic cyst in the skin is reported in a 5-year-old boy. This is the first case report of cutaneous bronchogenic cyst presenting as a distinct, pedunculated growth with a sinus tract at the base. Embryogenesis, differential diagnosis, and treatment are discussed.
Twelve patients with cervico-thoracic tumors underwent transmanubrial approach during a 1-year period. All but two patients with NSCLC (n = 8), had double approaches. Three cases with cervical esophageal cancer underwent TMA and laparotomy. The last patient underwent TMA for cervical fibrosarcoma. One patient underwent subclavian artery resection, while another one resection of the left brachicephalic vein with graft replacement. Two cases, in the esophageal cancer group, had laryngeal nerve palsy requiring temporary tracheostomy. TMA affords an excellent exposure of the thoracic in/outlet allowing extended resection. Sparing the main osteo-muscular structures, it respects shoulder mobility of the scapular girdle, thus avoiding deformities due to clavicle resection.
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Acinic cell carcinoma of parotid gland as cause of distant metastases are rare. The patient was a 60-year-old woman who had in 1993 a acinic cell carcinoma of right parotid gland. Tumour can be resected through total parotidectomy with facial nerve anastomosis and modified radical neck dissection (T (3) N (2b) M (0)). Since the operation the patient has remained symptom-free without any sign of tumour recurrence. After 12 years the patient noted swelling in the region of sternum and biopsy was necessary. Histologically and immunohistochemically the diagnosis of distant metastase on acinic carcinoma of the parotid gland was confirmed.
Vacuum Assisted Closure (V.A.C.) is a sound strategy to control severe post-sternotomy infection. Secondary re-wiring of the sternal bone or reconstructive surgery may be required later to achieve complete wound closure. Ten patients with severe sternal bone infection underwent initial V.A.C. therapy and delayed surgery for wound closure. Complete wound healing was achieved in all cases. As a case report we describe a patient with right-sided mastectomy and irradiation for breast cancer, who developed severe post-sternotomy infection and sternal bone necrosis following CABG. A combination of V.A.C. therapy and surgical reconstruction using a pedicled latissimus dorsi musculocutaneous flap led to complete wound closure.
Osteomyelitis of the sternum is a dreaded complication after sternotomy and is related to high mortality. Control of infection by radical debridement is the key to successful treatment. Instability of the thoracic cage can lead to a high complication rate. 16 Patients with an infected and unstable sternum underwent radical debridement with resection of the sternum and adjacent ribs. 6 Patients (group A) received an immediate defect coverage with a pedicled muscle flap. 10 Patients (group B) were treated with a vacuum-assisted closure (V.A.C.)-therapy until stabilization of their general condition and underwent defect coverage in a second operation. Healing of the flaps was uneventful in all cases despite minor problems. 5 patients of group A had severe complications with pulmonary or cardiac failure and thoracic instability which lead to prolonged periods of mechanical ventilation. 2 patients of this group died due to multi organ failure. All patients of group B survived and there were no major complications. All of the patients were free of recurrence from their osteomyelitis during follow-up. V.A.C.-therapy after radical resection of sternum osteomyelitis proved to be an effective measure to bridge time while optimizing the status of the patient and it's wound. With this approach we believe to have lowered the rate of major complications in this multi-morbid patient group by reducing the burden of one large operation and by improving thoracic stability.
Transverse sternal bone defects as a result of surgery or trauma remain an important clinical condition with serious sequelae. Patients sometimes complain of local pain during movement and breathing. Usually, defects are filled with prosthetic materials which remain permanently IN SITU. Small defects can be treated with autogenous bone grafts, whereas large defects are difficult to stabilize with common osteosynthetic techniques. Here, we report a new surgical technique using flexible intramedullary nailing ("Elastic Stable Intramedullary Nailing"--ESIN or "Embrochage Centro-Medullaire Elastique Stable"--ECMES) to stabilize a sternal defect after surgical removal of an osteochondral lesion. The defect was bridged by two elastic titanium nails and an autogenous corticocancellous bone graft. This new surgical technique showed a good clinical and functional outcome.
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We report a case of manubriosternal disjunction and review the literature. We describe a new approach for surgical repair with direct suture with PDS ropes.
Dislocations of sternal segments in children are extremely rare lesions; only seven sterno-manubrial dislocations have been reported in the literature. We present a case of posterior sterno-manubrial dislocation in a 9-year old gymnast exercising on parallel bars. We preferred performing an open reduction and plate stabilization using an angular stable implant, because of pain and respiratory distress. This technique of stabilization has not been described in the literature before and present the advantage of combining a high stability with a reduced risk of iatrogenic retrosternal injury. The plate stabilization led to an immediate amelioration of symptoms. The plates could be removed 4 months after initial treatment. The boy rapidly regained his sporting capabilities.