Successful surgical repair of complete sternal cleft in an adult

Modified surgical reconstruction technique for a rare isolated congenital sternal cleft: In a six -year-old child

We report the modified surgical reconstruction technique for correction for a large isolated congenital sternal cleft in 6 years old girl using a methyl methacrylate marlex mesh sandwich plate (MMS). The patient was referred to our tertiary care institution with a sizeable anterior chest wall bony defect. There was a large bulging under the skin due to protrusion of mediastinal viscera and visible cardiac pulsations with breathing. A chest x-ray and computed tomographic scan (CT) of the thorax was done to evaluate the bony defect. We reconstructed the sternal bony defect by our innovative technique using methyl methacrylate. The patient was discharged after three days for further follow up in outpatient. One year follow up patient is doing well with excellent results. Our technique is simple, cost-effective, and provides a perfect cosmetic effect for children's sternal large defects.

INTRODUCTION

Sternal clefts are rare congenital malformations that result from the defective embryologic fusion of paired mesodermal bands in the midline. This rare anomaly incidence is 1:100,000 cases per live births, which constitute 1% of all congenital chest wall deformities. The first Case of the sternal cleft was reported in 1740. The hereditary sternal gap is rare, and hence sporadic cases have been reported in the medical literature. Ravitch described that the first surgical correction was reported by Lannelongue et al., in 1988., But Burton published the first successful repair in 19474. An isolated sternal cleft is a rare entity and is classified into two categories' complete and incomplete sternal gap. Early repair is recommended; otherwise, surgical correction is challenging in children as the hypo plastic sternal edges cannot be approximated primarily, and this requires prosthetic, autologous grafts or some kind of parasternal chondroplasties.

CASE PRESENTATION

Since birth, a six-year-old girl was referred to our tertiary care center with a large central chest wall defect. She was a full-term normal delivery with no other congenital malformations. The defect was noticed at birth and became more evident as she grew up. In addition to cosmetic concern on coughing, there was bulging under the skin and visible cardiac pulsation. On examination, there was a large gap (7cm) in the midline of the chest with sternal adages well apart, moving independently.

DISCUSSION

The sternal cleft is a congenital anomaly with less than 0.15% and is more common in the female gender. Isolated sternal cleft without any other associated abnormalities is very rare. It has been reported as a part of defined syndromes like PENTALOGY OF CANTRELL, VACTREL, DANDY WALKER, and PHASE (Posterior fossa brain malformation, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormality).6 Embryo logically sternum originate from the somatic layer of lateral mesodermal plates as bilateral bands. They fuse in the midline by the 10th week to constitute a cartilaginous framework of manubrium, sternum, and xiphoid process. Failure of this fusion can lead to a partial or complete sternal cleft.7 Etiology of this disease is unknown; however, it has been linked with riboflavin or methyl-cobalamin deficiency, high alcohol intake during pregnancy.

CONCLUSION

in conclusion, our improvised reconstruction technique for large sternal cleft in children has several advantages. There is no need to do extensive chordotomies or using bone grafts. Less complicated procedure Provides more rigid frame for protection of thoracic structures and better chest wall stability. Hospital stay is minimal and is very cost-effective. The child's future growth is not affected as ribs and costal cartilages are left intact in this technique. There is no chance of displacement or excursion of the MMS plate. In female patients, this provides better cosmoses as there is no need to mobilize the pectoralis significant muscles flaps for coverage. The geometry of the rib cage is well preserved.

Congenital sternal defect repair in an adult cat with incomplete pentalogy of Cantrell

CASE DESCRIPTION

A 1-year-old spayed female domestic shorthair cat was evaluated for a sternal defect and ventral abdominal wall hernia.

CLINICAL FINDINGS

The cat appeared healthy. Palpation revealed a sternal defect, and the heart could be observed beating underneath the skin at the caudoventral aspect of the thorax. A 3-cm-diameter freely movable mass, consistent with a hernia, was also palpated at the cranioventral aspect of the abdomen. Thoracic radiographic and CT images revealed a sternal cleft, cranial midline abdominal wall hernia, and peritoneopericardial diaphragmatic hernia (PPDH).

TREATMENT AND OUTCOME

Thoracotomy and celiotomy were performed. The sternal cleft was repaired with a porcine small intestinal submucosa graft, titanium contourable mesh plate, and interrupted 25-gauge cerclage wires. A diaphragmatic herniorrhaphy was used to correct the PPDH. Thoracic radiographs were obtained immediately after surgery to confirm repair of the sternal cleft, abdominal wall hernia, and PPDH and at 1 and 3 months after surgery to assess the surgical implants, which had not migrated and were intact with only mild bending at the cranial and caudal margins of the mesh plate. At both recheck examinations, the cat appeared healthy with no complications reported by the owner.

CLINICAL RELEVANCE

A novel surgical technique was used to successfully repair a large sternal cleft in an adult cat with no postoperative complications reported. This technique may be useful for the treatment of sternal clefts in other cats. This was the first report to describe an adult cat with congenital defects consistent with incomplete pentalogy of Cantrell.

Congenital Sternal Cleft along with Persistent Left-Sided Superior Vena Cava: A Rare Presentation

Congenital sternal cleft is a rare abnormality resulting from fusion failure of sternum. It occurs in isolation or along with defects of abdominal wall, diaphragm, pericardium, and heart. Early surgical correction is required to protect the underlying structures for risk of cardiac compression. Here we report a case of 20-day female child presenting with congenital sternal cleft associated with multiple congenital heart disease and left-sided superior vena cava. She was operated by the cardiothoracic surgical team successfully and is doing well on followup. We discuss this rare case, imaging studies, and surgical strategy.

Congenital sternal cleft

We describe a rare case of congenital sternal cleft. Multidetector computed tomography showed the counterclockwise rotation of the heart. Primary surgical correction was successfully performed using the Sabiston technique when the patient was 20 days old. Although the circulatory and respiratory status was unstable in the immediate postoperative period, this abated, and the patient was discharged without complications on the 13th postoperative day. Postoperative multidetector computed tomography showed that the heart approached the normal position.

Phenotypic spectrum and management of sternal cleft: literature review and presentation of a new series

Sternal cleft is a chest wall malformation that can expose mediastinal viscera and vessels to injuries. It can be classified into two forms, complete and partial. Its etiology and incidence are unknown and it is often associated with other defects. The aim of this article is to review the literature and report our experience with this rare anomaly, focusing on clinical presentation and management. We reviewed the English written literature about sternal cleft and collected the clinical data of all the published series. We present seven new cases that we have observed and treated since 1999. Literature reports 51 series including 86 patients, more frequently female (62%) and affected with partial superior form (67%). Sternal cleft is often asymptomatic (74%) and associated with other defects (72%). Surgical treatments include primary closure (73%), bone graft interposition (10%), prosthetic closure (7%), and muscle flap interposition (3%). In our series, primary closure was possible in four cases, while in three cases we placed a prosthesis. Five patients had associated defects and two were affected with PHACES (posterior fossa abnormalities, hemangiomas, arterial lesions, cardiac abnormalities/aortic coarctation, abnormalities of the eye, and sternum defects) syndrome. We report for the first time the association of sternal cleft with connectival nevi in three of our patients. At follow-up, we observed no major complication or recurrences. Although primary closure is the preferred option and should be performed in the neonatal period, the use of prostheses warrants good results as well. Prior to treatment, associated defects and syndromes should be excluded.