Sternocostal dislocation following open correction of pectus excavatum-"stairway phenomenon": complication management by means of sternocostal locking titanium plate osteosynthesis

Operative treatment of multiple costochondral dislocations in a patient with severe rib fractures and a flail chest following trauma

A 73-year-old male patient underwent operative treatment for dislocation of multiple costochondral junctions alongside multiple bony rib fractures and a flail chest following high-energy trauma. During the operative fixation of the flail chest, the costochondral lesions were surgically stabilised with plates and screws, which were fixated on the osseous anterior rib, sternum or the rib cartilage. The patient experienced no pulmonary complications during the primary admission. At 7 months after the trauma, the chest CT scan showed full consolidation of all fixated rib fractures, including the costochondral lesions, without hardware dislocation or complications. The patient did not require any pain medication and had no pain during daily activities, at rest or at night. Although being a biomechanically demanding region, which is often not defined in current rib fracture classification, operative treatment of costochondral lesions is feasible with outcome similar to the treatment of bony rib fractures.

From pullout-techniques to modular elastic stable chest repair: the evolution of an open technique in the correction of pectus excavatum

BACKGROUND

Traditionally open procedures have been replaced by minimally invasive techniques in the correction of pectus excavatum. Efforts to improve the extent of mobilization of the chest wall and its stabilization have led to constant modifications. There is currently no consensus about the best procedure for correction of pectus excavatum.

METHODS

Based on the contributions of a single institution for the last 60 years, we present the various strategies used for the correction of pectus excavatum and the evolution of operational procedures. These approaches are compared with those performed internationally at similar periods.

RESULTS

Resections with external extension achieved moderate results and were modified in 1962 to the "Shred" method. The establishment of the "Strut" method in 1963 and, in 1977, its extension with the erection of the lower rib arches significantly improved patient outcomes. The "minimization" of the procedure in 2006 was accompanied by an increase in wound healing disorders and recurrent deformities. Since 2010, elastic stable chest repair (ESCR) has provided lossless mobilization and sternal elevation for healing costosternal pseudarthrosis and allowed correction of complex recurrences with excellent cosmetic-functional results. Strong asymmetric or broad-base deformities can now be stabilized using a modular hybrid technique of transsternal bar and locked plates.

CONCLUSIONS

ESCR marks the end of the 60-year development of an open procedure and, after loss-free mobilization of the chest wall by elastic-stable biomechanical management, optimizes the possibility of anatomical reconstruction of the chest wall during initial and re-interventions, achieving a permanent, physiologically stable remodeling of the chest wall.

Elastic stable chest repair and its hybrid variants in 86 patients with pectus excavatum

Background

Complex and mature funnel chest deformities are traditionally managed with open surgical procedures. Elastic stable chest repair (ESCR) has been used successfully and safely for relapse corrections. Does pure plate osteosynthesis in ESCR allow comparable corrective potency and implant safety as hybrid methods with metal bars?

Methods

Data from 86 patients with open funnel chest correction between 2011 and 2015 were analyzed in this retrospective study. Exclusion criteria included being under 12 years of age, and having a history of septic wound healing disorder or other malignant diseases. Main groups consisted of ESCR and hybrid techniques, subgroups were primary and recurrence correction. Correction results and follow-up examinations at six and 12 weeks and at 1 year were statistically analyzed.

Results

A total of 38 ESCR and 48 hybrid methods were analyzed. Bar implantation was required in 77% (recurrence 34%) of patients. All patients received plates with different combinations e.g., longitudinal-sternal, costosternal and costo-sterno-costal. In all groups, follow-up uptake showed a funnel chest correction result at the anatomical level with healthy values according to the Haller index (ESCR 4.36-2.84, hybrid 6.99-2.74, P<0.001). No material dislocations were observed in any subgroup.

Conclusions

ESCR and hybrid techniques represent promising and safe therapeutic approaches.

The oblique fracture of the manubrium sterni caused by a seatbelt--a rare injury? Treatment options based on the experiences gained in a level I trauma centre

INTRODUCTION

Sternal fractures are rare with 3-8 % out of the total number of trauma cases mostly caused by direct impact to the anterior chest wall. Most cases described are due to motor vehicle crash either caused by direct impact to the steering wheel or by the seat belt. Fractures mainly occur to the sternal body. Only rarely are cases of manubrium fractures described in literature, for example, in relationship with a direct impact to the shoulder which caused an oblique fracture near to the sternoclavicular joint. Three patients with profoundly dislocated oblique manubrium fracture were admitted to our Level I Trauma Center in 2012 and 2013. Those patients suffered from instability of the upper sternum and the shoulder girdle.

MATERIAL AND METHODS

Between January 2012 and October 2013, a total of 538 trauma patients were admitted to the emergency room and received whole body CT-scan. They were analysed retrospectively for sternal fractures. In cases of instability and dislocation, fracture stabilisation was performed by anterior plating through a medial approach using low profile titanium plates (MatrixRib®).

RESULTS

Seventy-nine (14.7 %) patients showed sternal fracture, out of which 13 (2.4 %) patients showed a fracture of manubrium, ten caused by seatbelt. In three cases stabilization was performed. Follow up showed sufficient consolidation without complications.

DISCUSSION

A total of 16.5 % of sternal fractures were localized at the manubrium, mostly caused by seat belt. Fractures without significant dislocation seemed to be stable and healed well under conservative treatment. Dislocation in this region leads to unstable shoulder girdle. Anterior plating provides sufficient stabilisation and allowed consolidation.

Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method.

This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture’s morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures.

Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels.

Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.