Endoscopic correction of pectus excavatum

Endoscopic surgery is minimally invasive and can be used to achieve superior cosmetic results. Conventional correction of pectus excavatum results in a long scar. Correction by use of endoscopic surgery involves a smaller skin incision. In this study, endoscopic correction of pectus excavatum was performed in 20 cases. A small transverse skin incision was made above the xyphoid process. A wide area beneath the pectoralis major muscle was dissected under endoscopic visualization. Subperichondrial resection was performed under direct visualization when possible. Subperichondrial resection of the third or fourth rib was performed under endoscopic visualization. Ravitch's chondrotomy of the second or third rib was performed under endoscopic visualization. Endoscopy was also useful for sternal elevation, with minimal risk of pleural perforation. Kirschner wire was inserted percutaneously under the sternum to prevent postoperative paradoxical respiration. In all cases, the postoperative course was uneventful. The advantages of endoscopic pectus excavatum correction are a short scar, control of bleeding, safe dissection of the pleura from the sternum without the risk of pleural perforation, and ease of sternal elevation without injury to the intramammary vessels. However, the endoscopic operation is long and is not useful in adults because subperichondrial resection in adults is difficult to perform.     

Comparing minimally invasive funnel chest repair versus the conventional technique: an outcome analysis in children

Surgical correction of pectus excavatum in children has gained new momentum since the introduction of the new minimally invasive repair by Nuss. To date, no studies directly evaluate the outcome of the new technique versus that of the conventional technique. From 2000 to 2002, 28 patients underwent pectus excavatum correction in the authors' hospital. Twenty-one were treated by minimally invasive repair of pectus excavatum and seven patients had open correction. Intraoperative and postoperative complications, clinical outcome, and patient satisfaction were evaluated. In the minimally invasive repair of pectus excavatum group, the children were younger (14.4 +/- 2.9 versus 17.8 +/- 3.2 years), had shorter operation times (53 +/- 18 versus 125 +/- 6 minutes), and had less blood loss (minimal versus 380 +/- 175 ml). No intraoperative complications were recorded. In the conventional group, two pleural lacerations occurred. Early postoperative complications in the minimally invasive repair group included two pneumothoraces and one case of pleural effusion. In the conventional group, one pneumothorax and one case of pleural effusion occurred. Late postoperative complications in the Nuss group included one costal erosion, two bar dislocations, one severe wound infection requiring bar removal, one hematothorax, and one case of postpericardiotomy syndrome; in the conventional group, there was one severe wound infection. In both groups, the patients rated their cosmetic results as good to very good. Minimally invasive repair of pectus excavatum is a novel method with clear advantages, such as limited surgical trauma and small scars. The high rate of postoperative complications may decrease with growing experience in the future. In well-selected patients (age, symmetric deformity), the Nuss procedure may become the method of choice. However, there is still a lack of long-term follow-up.     

Internal fixation of the sternum in median sternotomy dehiscence.

Sternal dehiscence may be defined as separation of the bony sternum and manubrium following median sternotomy. It may occur at any time postoperatively and has various etiologies. Restoration of sternal integrity in sternal dehiscence is a challenging problem, particularly when associated with deep-seated infection. This report reviews a single-stage technique that virtually eliminates the infected sternotomy wound and provides anatomic reduction and stabilization of the sternum. Complete debridement of infected and/or nonviable soft tissue, bone, and cartilage is followed by pulse irrigation. Parallel stainless steel mandibular reconstruction plates are then placed on each side of the remaining sternum and wired together. One or more transmanubrial compression plates may be added. Bilateral pectoralis major musculocutaneous flap advancement and primary skin closure is performed over two to three closed suction drains. From January of 1994 to July of 1996, this technique was used by the same surgeon in 26 male and 4 female patients aged 43 to 78 years (mean = 61). Indications for the operation were sternal dehiscence with infection (osteomyelitis and/or mediastinitis) in 14 patients and sternal dehiscence without infection in 16 patients. All patients survived to discharge with mean time on the ventilator, intensive care unit length of stay, and postoperative length of stay of 0.7, 2, and 8 days, respectively. Choice and duration of antibiotics were based on culture results and operative findings. Subsequent hardware removal was necessary in one patient for hardware loosening and three patients for late periplate infection. A closed wound was eventually achieved in all 30 patients, and sternal stability was restored in 29 patients. In the management of sternal dehiscence, the described technique of internal fixation can provide anatomic sternal reduction and stabilization, elimination of infection, and wound closure in a single-stage operation. Successful outcomes were achieved despite the presence of severe infection.     

Costal cartilage sculpturing as an adjunct to augmentation mammaplasty

Costal cartilage irregularities are a major component of most congenital thoracic-wall deformities. A significant number of patients with these cartilage irregularities may either refuse major reconstruction or in fact have disorders of insufficient magnitude to justify such endeavors. In patients undergoing augmentation mammaplasty, recontouring or sculpturing of these abnormal costal cartilages may correct or improve the underlying chest-wall deformity and thus enhance the final aesthetic result. This method has had application in mild to moderate asymmetrical cases of both pectus excavatum and pectus carinatum, thoracic hypoplasia (Poland's syndrome), isolated cartilage deformities, and spinal scoliosis. In our hands, the combination of cartilage sculpturing with submuscular augmentation mammaplasty is performed as an outpatient local anesthetic procedure requiring not more than 90 minutes.     

局限性小切口开胸术在胸外科中的应用

目的：通过对标准的胸外科手术切口与局限性小切口的对比,了解局限性小切口的优点。方法：146例患者,随机分为2组,分别行标准的胸外科手术切口与局限性小切口,观察2组术中失血量,术后3天胸腔引流量,住院时间,住院花费及术后疼痛程度。进行对比及统计学分析。结果：局限性小切口组的术中失血量,术后3天胸腔引流量,住院时间,住院花费及术后疼痛程度明显好于标准的胸外科手术切口组。结论：局限性小切口能够减少术中失血量及术后引流量。缓解术后疼痛,缩短住院时间,减少住院花费,是一值得推广的方法。     

The integrated approach to suppurative mediastinitis: rewiring the sternum over transposed omentum

Acute mediastinitis after cardiopulmonary procedures remains a devastating complication and a challenge to the reconstructive surgeon. A review of the literature and our own experience confirm the need for early aggressive drainage followed by timely reconstruction. In carefully selected patients, the sternum may be reclosed, provided that omental tissue has been transposed into the defect between the myocardium and the posterior cortex of the sternum. The technique is outlined and the results are analyzed and compared with three additional patient subgroups: (1) sternal wounds rewired over drains, (2) sternal wounds rewired with drains and irrigation catheters, and (3) wounds closed by sternal excision and muscle-flap transposition. To date, nine omental transfers have been performed with complete success. Mediastinal drainage routinely ceases after 3 to 5 days, and hospitalization has averaged 10 to 14 days. Early open debridement allows establishment of drainage and permits close evaluation of the character of the bony sternum. Muscle flaps may then be used in those patients with multiply fractured or frankly necrotic sternal tissue, while sternal closure over omental flaps may be used in all other patients. Adherence to this protocol has allowed for bacteriologic control of the wound, minimal morbidity, and no mortality.     

Correction of bilateral breast hypoplasia and pectus excavatum with single-unit customized silicone implant

The cosmetic defects of pectus excavatum and bilateral mammary hypoplasia can be corrected with a single-unit customized silicone implant. An extended pocket is made across the anterior chest wall through two inframammary incisions. It is then possible to insert and position the breast prostheses subpectorally and the sternal prosthesis subcutaneously using these incisions. A good cosmetic result can occur with minimal morbidity and scarring.     

Symptomatic pectus excavatum in seniors (SPES): a cardiovascular problem?: A prospective cardiological study of 42 senior patients with a symptomatic pectus excavatum

Objectives

There is no consensus among physicians as to whether or not pectus excavatum can produce symptoms sometimes even severe enough to justify a surgical procedure. The aim of this study was to assess the prevalence and severity of complaints and symptoms of senior patients with a pectus excavatum and to evaluate the results of surgical correction of the chest deformation.

Design

This is a prospective clinical study, case series.

Participants

The participants are 42 senior patients with a pectus excavatum and somatic complaints.

Methods

Cardiological screening included medical history taking, physical examination, electrocardiography, transthoracic echocardiography and treadmill cardiography. Complaints, symptoms and test results were arranged in a clinical score. Indication for a therapeutic surgical correction by a modified Ravitch operation was a high clinical score in combination with radiological evidence of cardiac compression on CT or MRI.

Results

The clinical picture of the 42 senior patients with a pectus excavatum showed complaints of fatigue and low exercise tolerance, shortness of breath, palpitations, inspiratory obstruction and sometimes chest discomfort or pain. The serious and sometimes invalidating complaints of 19 patients (45%) had started only in their fourth or fifth decade of life and were labelled in 12 patients (63%) as ‘Unexplained cardiovascular complaints’. To date, 11 patients have undergone surgical procedures. Symptoms were reduced substantially or had disappeared completely. All patients indicated that their health-related quality of life was significantly improved.

Conclusion

Recognising the clinical picture of SPES is relevant because surgical reconstruction of the chest can provide substantial relief of symptoms.     

Treatment of sternal nonunion with the Dall-Miles cable system

We have used this technique in two patients. One had early sternal dehiscence with presternal infection, and the other had late sternal nonunion. Uncomplicated sternal union was achieved in both patients. The cables were nonpalpable in both patients, but they were removed in one patient at that patient's request. This method of using Dall-Miles cerclage cables is a straightforward and efficacious method of open reduction and internal fixation of the sternum. It is indicated for patients with chronic sternal nonunion or early postoperative separation of the sternal fragments and may be used even in the presence of an infection limited to the presternal space after adequate debridement and irrigation have been performed. Any recurrent superficial infection, although unlikely, can be cured by hardware removal after osseous union has been obtained. For sternal separation without fractures, four cables may simply be placed around the sternal halves and their tension increased. In the case of sternal fractures, the cables may be placed in figures of eight or in other woven configurations as needed for each individual case.     

A rapid, secure method of sternal closure

In 1977 Robicsek(1) described a method of sternal closure that involved a double wire on each side of the sternum, with appropriate circumferential wires. Shortly thereafter, we modified that procedure, as shown in Figure 1. Only one wire is used on each side of the sternum, and fewer circumferential wires are needed. This type of sternal closure can be performed as rapidly as the usual closure of simple circumferential wire sutures and is much more secure, because the circumferential wires cannot cut through the parasternal wire. After using this method in about 100 patients with either poor sternal bone or chronic lung disease, we have encountered no subsequent sternal separation.     

锁定加压钢板行微创技术治疗老年性股骨远端骨折临床疗效分析

目的:评价用锁定加压钢板行微创技术治疗老年性股骨远端骨折的临床疗效。方法:自2012年1月到2015年6月间,我院用锁定加压钢板行微创技术治疗27例60岁以上老年性股骨远端骨折患者(其中1例为双侧),通过观察患者伤口愈合情况、骨折愈合情况及相关并发症,并采用Kolmert评分标准评价其临床效果。结果:本组27例患者均获得随访,其中1例患者(单侧)在术后25 d死亡,其余病例随访6-30月,平均14.7月,术后切口有1例延迟愈合,余均一期愈合,骨折在末次随访均骨性愈合,未见骨折移位、内固定物失效、骨折畸形愈合、骨折不愈合等不良并发症,根据Kolmert评分标准,优10例,良13例,可3例,差1例,优良率为85%。结论:锁定加压钢板行微创技术治疗老年性股骨远端骨折可达到固定牢固、能早期功能练习、术后并发症少、术后效果满意的疗效。     

Cell hypertrophy and type X collagen synthesis in cultured articular chondrocytes

Articular cartilage is a permanent tissue whose cells do not normally take part in the endochondral ossification process. To determine whether articular chondrocytes possess the potential to express traits associated with this process such as cell hypertrophy and type X collagen, chondrocytes were isolated from adult chicken tibial articular cartilage and maintained in long-term suspension cultures. As a positive control in these experiments, we used parallel cultures of chondrocytes from the caudal portion of chick embryo sternum. Both articular and sternal chondrocytes readily proliferated and progressively increased in size with time in culture. Many had undergone hypertrophy by 4-5 weeks. Analysis of medium-released collagenous proteins revealed that both articular and sternal chondrocytes initiated type X collagen synthesis between 3 and 4 weeks of culture; synthesis of this macromolecule increased with further growth. Immunofluorescence analysis of 5-week-old cultures showed that about 15% of articular chondrocytes and 30% of sternal chondrocytes produced type X collagen; strikingly, there appeared to be no obvious relationship between type X collagen production and cell size. The results of this study show that articular chondrocytes from adult chicken tibia possess the ability to express traits associated with endochondral ossification when exposed to a permissive environment. They suggest also that the process of cell hypertrophy and initiation of type X collagen synthesis are independently regulated both in articular and sternal chondrocytes.     

Treatment of total sternal necrosis using the latissimus dorsi muscle flap

Complications after a median sternotomy incision, which is used currently in most cardiac and mediastinal surgical procedures, although infrequent, are serious. If sternal dehiscence follows median sternotomy, infection extends to vital underlying structures, exposing the anterior part of the heart and ascending aorta. Permanent hemorrhage, septic thrombosis, or septic perforation of prosthetic material demand soft-tissue coverage. In 5 patients with total sternum necrosis the retrosternal space was covered with a latissimus dorsi muscle flap in order to achieve stable protection of the exposed mediastinal organs.     

Expression of matrix metalloproteinase-1 (MMP-1) in Wistar rat's intervertebral disc after experimentally induced scoliotic deformity

Minimally invasive spine surgery is becoming more common in the treatment of adult lumbar degenerative disorders. Minimally invasive techniques have been utilized for multilevel pathology, including adult lumbar degenerative scoliosis. The next logical step is to apply minimally invasive surgical techniques to the treatment of adolescent idiopathic scoliosis (AIS). However, there are significant technical challenges of performing minimally invasive surgery on this patient population. For more than two years, we have been utilizing minimally invasive spine surgery techniques in patients with adolescent idiopathic scoliosis. We have developed the present technique to allow for utilization of all standard reduction maneuvers through three small midline skin incisions. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, and allows adequate facet osteotomy to enable fusion. There are multiple potential advantages of this technique, including: less blood loss, shorter hospital stay, earlier mobilization, and relatively less pain and need for pain medication. The operative time needed to complete this surgery is longer. We feel that a minimally invasive approach, although technically challenging, is a feasible option in patients with adolescent idiopathic scoliosis. Although there are multiple perceived benefits, long term data is needed before it can be recommended for routine use.     

Minimally invasive approach to familial multiple lipomatosis

Thirty-five abdominal wall lipomas were removed from a patient with familial multiple lipomatosis using a minimally invasive approach in a cost-effective, reliable, and cosmetically pleasing manner. The surgical technique used is described in this case report. Clinical findings and prior excisions provided the preoperative diagnosis. The abdominal wall was dissected through two small, vertical midline incisions in the suprafascial plane with the aid of a lighted breast retractor. A complete excision of all palpable lipomas was achieved with this approach. The patient had excellent cosmetic results with minimal postoperative scarring.     

Elastostatic analysis of the human thoracic skeleton

An elastostatic, finite element model (designated THORAX I) of the human thoracic skeleton has been developed. The model includes the primary load-carrying members of the thorax; namely, the sternum, costal cartilage, ribs, and vertebral column. The soft tissue has been neglected.

Using gross geometric data measured from a skeleton with an apparent ‘small’ frame and approximate cross-sectional properties, the THORAX I model has been subjected to three loading distribution applied to the anterior chest wall in the anterior-posterior direction. Calculations were carried out on the IBM 7094 computer, and primary attention was focused upon the displacement fields of the sternum, costal cartilage and ribs and stresses in costal cartilage and ribs. The sternum and rib nodal point displacement fields are reported in detail, and a simple 2-degree-of-freedom model for the sternum, which correlates well with the analytic results, is also presented. Maximum normal stresses in the cartilage and bony regions of the individual ribs for one loading condition are also given.     

Anterior thoracic hypoplasia: a separate entity from Poland syndrome

SUMMARY: Women presenting with anterior thoracic depression, breast hypoplasia, and subsequent asymmetry are often diagnosed with Poland syndrome regardless of pectoralis involvement, or are placed in the generic category of breast asymmetry or skeletal dysplasias. Recently, though, the term "sunken chest" has been used to describe forms of chest wall depression that previously may have fallen under generic skeletal dysplasias. The authors believe that, combined with hypoplasia of the ipsilateral breast, superior location of the nipple-areola complex compared with the contralateral side, and normal pectoralis muscles, this represents a previously undefined and real condition called anterior thoracic hypoplasia. During the past 4 years, the authors have treated eight women who have presented with a diagnosis of Poland syndrome or pectus excavatum, all of whom share the same characteristics-unilateral sunken anterior chest wall, hypoplasia of the breast, superiorly placed nipple-areola complex, normal pectoralis muscle, and normal sternal position. All of the patients underwent correction of breast asymmetry and unilateral anterior thoracic hypoplasia with augmentation mammaplasty, a method that when tailored for each side yields good aesthetic results. The average age of the patients was 31 years and the average chest size was 34. Cup size, as measured by the patient's standard bra, was a B on the nonaffected side in all patients and an A on the affected side in all patients except one. Of the eight patients, seven had the right anterior chest and breast involved, whereas one patient had involvement on the left. For all of the patients, the nipple and areola of the hypoplastic side were smaller and in a more superior position compared with the contralateral side on visual inspection. In the eight patients, a total of 19 augmentations (15 primary augmentations and four revisions) and one mastopexy were performed. Ten inframammary-fold approaches and nine periareolar approaches were used, and all of the implants were placed in a partial submuscular position, except for two implants placed in a subglandular position that were converted to partial submuscular positions in a secondary setting. In all the women, the sternal head of the pectoralis muscle was present and the pectoralis muscle appeared to be equal in size compared to the contralateral side. Nine different types of implants were used. Average implant fill volume measured 412 cc on the hypoplastic side and 257 cc on the contralateral side. In follow-up, all of the patients were satisfied with their operation and rated their aesthetic outcome as very good to excellent. The authors believe that anterior thoracic hypoplasia is a real, previously misdiagnosed and undescribed condition, and that both chest wall and breast deformities can be corrected safely and with excellent results using proper augmentation planning and implant selection.     

Polytetrafluoroethylene bars in stabilizing the reconstructed sternum for pectus excavatum operations in children

Nine children with severe pectus excavatum deformity were operated on in the Department of Pediatric Surgery, Thoracic Unit, Ege University Faculty of Medicine, Izmir, Turkey. There were four boys and five girls, and the mean age at operation was 6.3 years. A modified Ravitch technique was performed by using two polytetrafluoroethylene bars placed retrosternally for fixation and stabilization of the reconstituted anterior chest wall. The bars were removed 6 months after the operation. Results were satisfactory in all cases, with no surgical complications.     

Abnormal structure of type II collagen in a patients with funnel chest

The electrophoretical analysis and CNBr-peptide mapping of the collagens, isolated from the costal cartilage of 30 patients with non-classified and syndromal forms of pex excavatum (funnel chest) (27 patients) and pex carinatum (3 patients) was carried out. In case of one patient with the nonclassified form of funnel chest the electrophoretical mobility of CB 9.7-peptide was found to be decreased. The electrophoretical mobilities of other peptides are not markedly changed. The data obtained allow one to suggest the mutation causing the defect in the region about 160 amino acid residues distant from the C-end of alpha 1 (II) chain of type II collagen of the patient.