Ann Thorac Surg 1998;66:1805-1806
© 1998 The Society of Thoracic Surgeons
Case Reports
Chest wall repair with a titanium instrument
Kiyoshi Ohno, MDa,
Keiji Kuwata, MDa,
Yoshio Yamasaki, MDa,
Katsuhiko Akizuki, MDa,
Iwao Satoh, MDb
a Department of Surgery, Osaka Kosei-Nenkin Hospital, Osaka, Japan
b Department of Orthopaedics, Osaka Kosei-Nenkin Hospital, Osaka, Japan
Accepted for publication May 9, 1998.
Address reprint requests to Dr Ohno, Department of Surgery, Osaka Kosei-Nenkin Hospital, Fukushima-ku, Osaka, Japan
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Abstract
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We performed chest wall repair with titanium alloy instruments as artificial ribs for prevention of paradoxical respiration and protection of the lung and liver after chest wall resection including the nearly entire length of the right seventh to the eleventh ribs and the costal arch for metastasis of osteosarcoma. The technique of this operation is presented diagrammatically.
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Introduction
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Various techniques for chest wall repair have been attempted for chest wall defects after resection of malignant diseases. Among them, suturing of Marlex mesh to tissues around the chest wall defect to retain tension is often employed for prevention of flailed chest [1]. However, this technique was difficult to apply to cases such as the following.
A 14-year-old boy with osteosarcoma of the left femur received wide excision of the tumor. Metastasis to the right chest wall was detected 2 years 4 months after the operation on the primary lesion, and the chest wall including the seventh and eighth ribs was resected completely from 3 cm from the spine to the costal arch. Seven months later, metastasis was noted again in the right chest wall. The tumor involved the ninth and tenth ribs from approximately 5 cm lateral to the spinous processes of the corresponding vertebra to near the sternum medially (Fig 1).
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Fig 1. Preoperative computed tomography showed invasion of the metastatic lesion (T) in the chest wall to almost the entire length of the ninth and tenth ribs and the costal arch.
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The resection of the tumor resulted in a wide defect of the lower margin of the chest wall including the costal arch and the seventh to the tenth ribs. In the repair of the chest wall with Marlex mesh, it would be impossible to apply the mesh with tension over the repaired area of the chest wall because of the lack of bony tissue to which the lower end of the mesh could be sutured; this was expected to result in paradoxical respiration and insufficient protection of the lung and the liver. In this patient, we repaired the chest wall with the following technique.
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Technique
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In the right-side–up position, a skin incision was made along the ninth rib to the costal arch. The Marlex mesh used in the previous operation was removed along the upper margin of the tumor, and abdominal and lumbar muscles were divided 5 cm from the lower margin of the tumor. The ninth, tenth, and eleventh ribs were cut 1 cm from the transverse process to the sternum. The diaphragm was dissected to the costal arch, the costal arch was cut, and the tumor was resected en-bloc. The diaphragm and the thoracic and abdominal wall were repaired with a material used for spinal fixation (ISOLA spinal system; AcroMed Corp, Cleveland, OH). A pedicle screw 4.75 mm in diameter was thrust into the left pedicles of the ninth and tenth vertebral arches to immobilize the slotted connector. Titanium rods 6.35 mm in diameter, which were shaped preoperatively to match the ninth and tenth ribs, were connected to the slotted connectors. Transverse fixators were attached between the rods at two points. The ventral end of each rod was not connected with the sternum (Fig 2). The diaphragm was repaired by suturing a polytetrafluoroethylene sheet to the rod fixed to the ninth thoracic vertebra and the resection margin of the diaphragm with sufficient tension. Then, to repair the thoracic and abdominal wall, two layers of Marlex mesh sutured to the rod fixed to the ninth thoracic vertebra were sutured with tension to the sixth rib and muscles of the abdominal and lumbar wall (Fig 3).
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Fig 2. Posterior view after resection of the tumor. Titanium rods were fixed to the left pedicles of the vertebral arches of the ninth and tenth thoracic vertebrae, and transverse fixators were applied between the rods at two points.
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Fig 3. Right lateral view. Two layers of Marlex mesh sutured to the rod fixed to the ninth thoracic vertebra were sutured with tension to the sixth rib and muscles (m.) of the abdominal and lumbar wall.
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No paradoxical respiration was noted after operation. However, a metastatic lesion appeared in the left thoracic cavity on chest x-ray films 42 days after the operation and rapidly increased, and the patient died of respiratory failure after 104 days.
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Comment
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Surgical treatments using various prostheses have been reported for large defects of the chest wall. However, in patients who have had chest wall resections, particularly those with wide defects of the lower margin of the chest wall including the costal arch, repair using Marlex mesh, polytetrafluoroethylene sheeting, silicone sheeting, or a Marlex-methylmethacrylate sandwich may result in paradoxical respiration and insufficient protection of the lung and liver after operation because of the poor rigidity of these materials and the technical difficulty of applying tension over the repaired area of the chest wall.
There are techniques in which metallic instruments such as stainless steel rods are fixed to the stumps of the resected ribs and the sternum as substitute ribs, but the steadiness of fixation of the metallic instruments may be reduced with respiratory movements when the rib defect is long [2]. We used a material made of titanium alloy for spinal fixation because this is highly biocompatible, although expensive compared with other metals [3] used as artificial ribs. Strong artificial ribs could be reconstructed, and they sufficiently permitted suturing of a polytetrafluoroethylene sheet or Marlex mesh with tension for the repair of the diaphragm, thoracic wall, and abdominal wall. As a result, no postoperative paradoxical respiration was noted. We also left the ventral ends of the rods free without fixing them to the sternum in expectation that this device would reduce the adverse effects of the instruments on the development of the thorax in growing patients.
In this patient, the chest wall prosthesis was not covered with rotated muscle flaps. However, we consider the addition of this procedure to be better, and will perform this procedure in future cases.
Titanium alloy cannot be used in patients with local or systemic infection, and further studies are necessary on the long-term stability of artificial ribs constructed from titanium alloy.
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References
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- Graham J., Usher F.C., Perry J.L., Barkley H.T. Marlex mesh as a prosthesis in the repair of thoracic wall defects. Ann Surg 1960;151:469-479.
- McCormack P.M. Use of prosthetic materials in chest-wall reconstruction. Surg Clin North Am 1989;69:965-976.[Medline]
- Williams D.F. Titanium: epitome of biocompatibility or cause for concern?. J Bone Joint Surg 1994;76:348-349.
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Abstract
Introduction
