HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): E. Dean McKenzie Charles D. Fraser Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tortoriello, T. A. Articles by Mott, A. R. Search for Related Content PubMed PubMed Citation Articles by Tortoriello, T. A. Articles by Mott, A. R. Related Collections Chest wall

Ann Thorac Surg 2003;76:1655-1660
© 2003 The Society of Thoracic Surgeons

---

Original article: general thoracic

Mediastinitis after pediatric cardiac surgery: a 15-year experience at a single institution

^a The Lillie Frank Abercrombie Section of Pediatric Cardiology, The Heart Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
^b Department of Congenital Heart Surgery, The Heart Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
^c Department of Plastic and Reconstructive Surgery, The Heart Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA

Accepted for publication May 5, 2003.

^* Address reprint requests to Dr Mott, The Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, 6621 Fannin, MC-19345C, Houston, TX 77030, USA.
e-mail: amott{at}bcm.tmc.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: The spectrum of sternal wound infections after cardiac surgery ranges from superficial infections to a deep sternal infection known as mediastinitis. Mediastinitis is a rare but clinically relevant source of postoperative morbidity and mortality in adult and pediatric patients after cardiac surgery.

METHODS: We retrospectively identified all patients diagnosed with mediastinitis after cardiac surgery from January 1987 to December 2002 (17 patients/7,616 surgeries = 0.2%). Demographic data, cardiac diagnosis, cardiac surgery, hospital length of stay, associated medical diagnosis, and surgical treatment for mediastinitis were collected.

RESULTS: Fifteen pediatric patients (age < 18 years) were diagnosed with mediastinitis (mean age at diagnosis 37.5 months, range 21 days to 17 years. The median postoperative day of diagnosis was 14 days (6 to 50 days). The most common organism was Staphylococcus species (n = 9). Six patients had an associated bacteremia. The median hospital length of stay for all patients was 42.5 days (range 16 to 163 days). The hospital mortality was 1 of 15 (6%). Each patient was treated with intravenous antibiotics; sternal debridement; and rectus abdominus flap reconstruction (n = 7), pectoralis muscle flap reconstruction (n = 3), omentum reconstruction (n = 1), or primary sternal closure (n = 4). Three patients have undergone redo-sternotomy with orthotopic heart transplantation, bidirectional cavopulmonary anastomosis, and replacement of a right ventricle to pulmonary artery homograft.

CONCLUSIONS: Timely diagnosis, aggressive sternal debridement, and liberal use of rotational muscle flaps can potentially minimize the morbidity and mortality in pediatric postoperative cardiac patients. Subsequent redo-sternotomy has not been problematic.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Sternal wound infections after cardiac surgery requiring median sternotomy continue to represent a rare but important complication that is associated with significant morbidity and mortality [1–3]. The reported incidence is less than 2% of all cardiothoracic procedures. This complication occurs despite established preoperative prophylaxis strategies. Staphylococcal species continue to be the most common offending organisms. The severity of postoperative wound infection ranges from a superficial wound infection (which involves only skin or subcutaneous tissue) to fulminate mediastinitis with subsequent involvement of the sternum (sternal dehiscence and osteomyelitis) and organ tissues outside the incision [4].

In most adult series, the reported incidence of sternal infections ranges from 0.9% to 20% [5, 6] and for mediastinitis 1% to 2% [7, 8]. The mortality for postcardiotomy deep sternal infection continues to be high, between 14% and 47%, despite early diagnosis and appropriate treatment [6, 9–12]. Early diagnosis of mediastinitis and the implementation of an effective treatment strategy are required to avoid mortality among these patients.

Several reported adult studies have attempted to identify patient-related risk factors for the occurrence of mediastinitis. These risk factors include older age, male sex, obesity, diabetes mellitus, chronic obstructive pulmonary disease, and procedure-related factors such as prolonged preoperative stay, duration of surgery, use of bilateral internal mammary artery grafts, reoperation for control of bleeding, and the need for repeat blood transfusions [5–7, 9, 11, 13, 14]. Although attempts to define true risk factors have been made, corroboration has been inconsistent at best.

Despite the frequency with which the median sternotomy incision is used in pediatric cardiovascular surgery, few reports have discussed the diagnosis, management, and treatment strategy of mediastinitis in children. The purpose of our study was to describe the clinical profile, bacteriologic and therapeutic features, and evolving management strategy for pediatric postoperative cardiac surgery patients who have been diagnosed with mediastinitis.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patient selection
A retrospective review of the cardiology database at our hospital identified 7,616 consecutive cardiac surgical procedures from January 1, 1987, through December 31, 2002. During this period, 17 patients (0.2%) were diagnosed with mediastinitis after a corrective or palliative procedure that required a median sternotomy incision. Of the 17 patients diagnosed with mediastinitis, 15 were pediatric patients (age < 18 years). These 15 patients were the focus of this report. To ensure that all cases of mediastinitis were identified, the positive culture logs from the Department of Infection Control were reviewed to identify all positive cultures from median sternotomy incisions, and the diagnosis of mediastinitis was confirmed after comparing both the cardiology and infection control databases.

Data collection
Data collected for each patient included: demographic data; cardiac diagnosis; primary cardiac repair; associated medical diagnosis; preoperative, perioperative, and postoperative events and complications; positive culture results from wound or blood specimens; clinical course; and therapeutic management. The chart review was approved by our institutional review board.

Definitions
A deep sternal wound infection was defined according to the guidelines of the Centers for Disease Control and Prevention [4]. Superficial surgical site infections (SSI) involve only skin or subcutaneous tissues, deep SSIs involve deep soft tissues (fascial and muscular layers), and organ/space SSIs involve tissues other than the incision. Postoperative mediastinitis is defined as an organ space SSI. The cardiac surgeons' operative reports on revisions (deep sternal infections, mediastinitis) were reviewed to ensure that definitions were in accordance with these classes. The use of surgical sternal reconstruction for mediastinitis with pectoralis muscle flaps [15–17], rectus abdominus muscle flaps [15, 17], and omental flaps [18] has been described previously.

Sternal instability was defined as evidence of sternal bone disunion without disunion of the skin. Sternal dehiscence was defined as evidence of sternal incision disunion with sternal bone disunion. Chest radiograph findings included mediastinal widening in 4 patients and malposition of the sternal wires in 2 patients.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Primary cardiac operation
Fifteen cardiac operations were performed (Table 1). The mean age at the time of the primary cardiac surgeries was 37.5 months (range 21 days to 17 years). Ten patients had undergone 18 previous cardiac operations requiring median sternotomy incisions (n = 11) and thoracotomy incisions (n = 7). Five patients had not undergone a previous sternotomy or thoracotomy. Of the 15 cardiac surgeries performed, 14 required cardiopulmonary bypass and 12 surgeries were elective procedures.

All patients received perioperative antibiotic prophylaxis with intravenous cefazolin. One patient at the time of cardiac surgery was noted to have sternal nonunion with pseudoarthrosis and thickening but no evidence of chronic infection. Postoperative complications included delayed sternal closure in 2 patients, emergent sternotomy in 3 patients, and a ventricular assist device in 1 patient (Table 1).

Eleven patients had postoperative evidence of bronchospasm/reactive airway disease that required nebulized ß-agonist treatments. Nine patients received steroids: intraoperatively, solumedrol (n = 3); postoperatively, immunosuppressive agents for orthotopic heart transplantation (OHT; n = 2), bronchospasm/reactive airway disease (n = 2), and prior to tracheal extubation (n = 2).

Mediastinitis
Diagnosis
Mediastinitis was diagnosed in 15 patients: 10 males and 5 females. The hospital mortality was 1 of 15 (6%). The nonsurvivor (patient 3) was a 6-month-old who was status post-OHT in whom fungal mediastinitis had been diagnosed 60 days after median sternotomy and who died secondary to multisystem organ dysfunction. A second patient (patient 1) with tricuspid atresia and status post-atriopulmonary Fontan died of intractable ventricle arrhythmias 4 years after her primary cardiac repair and treatment for mediastinitis. The mean duration of follow-up for all survivors was 3.2 years (range 112 days to 10 years).

Mediastinitis was diagnosed on median postoperative day 14 (range 6 to 50 days). Five patients were diagnosed after having been discharged to home and 10 were hospital inpatients. At the time of diagnosis, the sternotomy incision was described as being erythematous (n = 8), fluctuant (n = 7), or indurated (n = 3). There was also the presence of fever (temperature > 101.5°F) (n = 12), purulent discharge from the sternotomy incision (n = 9), sternal instability (n = 5), and dehiscence (n = 4) at the time of diagnosis.

A summary of the organisms cultured from the sternum, trachea, and blood is described in Table 2. Of note, 6 patients also had an associated bacteremia at the time of diagnosis. In the patient with a tracheostomy tube (patient 7), Pseudomonas aeruginosa and Serratia marcescens were cultured from both the sternal wound and trachea. In the patient with the gastrostomy tube (patient 14), Pseudomonas aeruginosa was cultured from the sternum. Of the 2 patients (patients 3 and 5) diagnosed with Enterobacter cloacae mediastinitis, the same organism was also cultured from the trachea. Patient 5 had radiographic evidence of pneumonia.

Three patients have since undergone redo-sternotomy: bidirectional cavopulmonary anastomosis (patient 6), placement of a right ventricle to pulmonary artery homograft (patient 8), and OHT (patient 12). In the patient undergoing bidirectional cavopulmonary anastomosis, the sternotomy reconstruction site was described as having complete sternal nonunion. The rectus abdominus muscle, though viable, was atrophied. The rectus abdominus muscle was easily mobilized and excised and the sternum was reapproximated primarily using interrupted stainless steel wire. No patient has had recurrence of mediastinitis, although 1 (patient 8) had a superficial sternal infection with coagulase-negative Staphylococcus after reoperation.

Secondary to disunion of the sternum, one patient (patient 10) underwent further sternal reconstruction 2 years after the initial reconstruction. Findings at reoperation included sternal nonunion with a viable but atrophied rectus abdominus flap. The rectus abdominus muscle was mobilized and removed, and the sternum was reapproximated with sternal wires.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
In 1957, Julian and associates [19] first used a median sternotomy incision to perform cardiac surgery. Infections of the median sternotomy incision have since become a significant source of postoperative morbidity and mortality. Although the incidence of mediastinitis is low—less than 2% of all cardiac surgeries—when it occurs a patient's perioperative course can be radically altered. The diagnosis of mediastinitis is challenging. Essential to achieving improved results is a consistent surgical management strategy and timely clinical "suspicion" of mediastinitis. In our series, although sternal instability and sternal dehiscence were present, incision cellulitis and fever were the more common presenting signs. Associated bacteremia was present in at least 40% of patients.

The optimal treatment of mediastinitis, once diagnosed, remains controversial. Management strategies have evolved from debridement with antibiotic irrigation and sternal closure to the liberal use of omental flaps or rotational pectoralis and rectus abdominus muscle flaps, especially in adults. Backer and colleagues described the use of vascularized muscle flaps in pediatric patients with life-threatening mediastinal wounds, only 2 of whom had mediastinitis [15]. We have incorporated an aggressive surgical strategy of extensive surgical debridement and early sternal reconstruction with either omental flaps, pectoralis major muscle flaps, or rectus abdominus muscle flaps. Since 1996, only 1 patient in our series has had primary direct sternal closure (patient 15).

Compared with other strategies, our strategy is aggressive but our mortality results compare favorably with previously reported results. Early debridement of the sternum and use of rotational muscle flaps and omentum (1) expedites wound healing; (2) improves blood supply to the sternum, an adjunct to the effective treatment of osteomyelitis; and (3) allows for reapproximation of the sternum at subsequent operations, as was the case with 2 patients who had elective repeat cardiac operations using median sternotomy incisions.

The choice of rotational flap to be used is dependent on surgeon preference and other factors such as patient age, size, and gender. The presence of percutaneous enterostomies can also influence the type of rotational flap. An omental flap is used in the older patient and when the sternal defect is not as extensive. A disadvantage of this flap is the potential for hernia formation and an inability to cover the defect adequately given the thinness of the omental tissue. Because of the increased length of the abdomen in comparison with the chest in small children, a rectus abdominus muscle flap allows complete coverage of the sternal incision and reaches the central extent of the wound. A potential disadvantage is the relatively large abdominal incision and scar formation that results from the use of this flap. A pectoralis major muscle flap is a simple advancement that provides a large area of soft tissue and avoids the need for an abdominal incision. The technique is limited, however, by the sternal wound position in that it does not adequately cover the lower one third of the sternal incision. Care must also be taken with female patients because of the potential for disturbance of breast development with the use of a pectoralis major muscle flap.

The potential for impaired thoracic cage physiodynamics or limited exercise capacity are concerns. One patient (patient 10) underwent elective sternal reconstruction because of sternal instability. Although previous studies have raised the possibility of an increased risk of reoperation through the reconstructed sternum due to the small amount of tissue that is initially placed over the mediastinum [16], subsequent reoperation has been performed in 3 patients in our series and has not been problematic.

Recognizing predisposing risk factors for developing mediastinitis is also important to decreasing mediastinitis-related hospital mortality. Predisposing risk factors have been extensively described in adults, but limited data have been reported in pediatric patients. Children with asplenia syndrome are at increased risk of infectious complications [15, 21, 22]. Another risk group is the child who has undergone cardiac transplantation. Four patients in the present series had undergone either cardiac transplantation or had asplenia.

A possible association has been reported between the use of ß-adrenergic drugs and mediastinal infection. A 20-fold increase in the risk of postoperative mediastinitis in adults who required ß-adrenergic drugs after cardiovascular operations has also been reported [7]. Obstructive respiratory problems may place mechanical strain on the sternotomy incision creating sternal instability [7, 10, 11] and sternal dehiscence [23–25], which may lead to seeding of infection.

Mediastinitis can be caused potentially from concomitant infections at other sites, such as the trachea. The organism is likely a gram-negative organism [26]. In our series, 3 of 4 patients with gram-negative mediastinitis had the same organism cultured from the trachea in 2 patients (one patient had radiographic evidence of pneumonia) and the gastrostomy tube site in the other. Outbreaks of mediastinitis caused by specific gram-negative organisms such as Pseudomonas or Serratia may suggest that nosocomial spread of gram-negative infections in the postoperative period is important for the development of gram-negative mediastinitis [27]. Strict enforcement of hygienic barrier routines to reduce the spread of nosocomial infections in the postoperative period is paramount to reducing this possible risk factor for mediastinitis.

A potential and formidable challenge to the successful treatment of mediastinitis is the ever increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) strains. The use of preoperative antibiotic prophylaxis has been effective in preventing infections of the sternotomy incision but at the risk of promoting the isolation of resistant strains. S aureus strains causing infections in nonhospitalized patients historically have been methicillin-susceptible strains. Nakamura and colleagues [28] noted an increase in community-acquired MRSA strains. Since the late 1990s, studies conducted in various cities in the United States, as well as in other countries, have revealed a significant prevalence of community-acquired MRSA strains [26, 28, 29]. Moreover, Sattler and associates [29] from our institution have noted that MRSA has become an established community-acquired pathogen in Houston, Texas. During a 10-month period, they noted that 35% to 51% of monthly S aureus isolates from children with community-acquired infections at our hospital were methicillin-resistant [29].

In summary, mediastinitis is a rare, but clinically relevant source of morbidity in pediatric patients who have had cardiac surgery. The changing resistance profile of staphylococcal species may warrant institutions to modify preoperative and perioperative prophylactic antibiotic strategies. The present review confirms that hospital mortality due to mediastinitis can be considerably reduced by having a high index of clinical suspicion of mediastinitis and an aggressive surgical strategy that incorporates early sternal debridement and the liberal use of rotational muscle flaps. ([20])

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Combes A., Trouillet J.L., Baudot J., Mokhtari M., Chastre J., Gibert C. Is it possible to cure mediastinitis in patients with major postcardiac surgery complications?. Ann Thorac Surg 2001;72:1592-1597.[Abstract/Free Full Text]
2. Ridderstolpe L., Gill H., Granfeldt H., Ahlfeldt H., Rutberg H. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg 2001;20:1168-1175.[Abstract/Free Full Text]
3. De Feo M., Gregorio R., Della Corte A., et al. Deep sternal wound infection: the role of early debridement surgery. Eur J Cardiothorac Surg 2001;19:811-816.[Abstract/Free Full Text]
4. Mangram A.J., Horan T.C., Pearson M.L., Silver L.C., Jarvis W.R. The hospital infection control practices advisory committee. Guideline for prevention of surgical site infection, 1999. Am J Infect Control 1999;27:97-134.[Medline]
5. Ulicny K.S., Hiratzka L.F. The risk factors of median sternotomy infection: a current review. J Card Surg 1991;6:338-351.[Medline]
6. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-187.[Abstract]
7. Bitkover C.Y., Gardlund B. Mediastinitis after cardiovascular operations: a case-control study of risk factors. Ann Thorac Surg 1998;65:36-40.[Abstract/Free Full Text]
8. Baskett R.J.F., MacDougall C.E., Ross D.B. Is mediastinitis a preventable complication? A 10 year review. Ann Thorac Surg 1999;67:462-465.[Abstract/Free Full Text]
9. Serry C., Bleck P.C., Javid H., et al. Sternal wound complications: management and results. J Thorac Cardiovasc Surg 1980;80:861-867.[Abstract]
10. Grossi E.A., Culliford A.T., Krieger K.H., et al. A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures. Ann Thorac Surg 1985;40:214-223.[Abstract]
11. Ottino G., Paulis R.D., Pansini S., et al. Major sternal wound infection after open heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987;44:173-179.[Abstract]
12. Ivert T., Lindblom D., Sahni J., Eldh J. Management of deep sternal wound infection after cardiac surgery-Hanuman syndrome. Scand J Cardiovasc Surg 1991;25:111-117.
13. Losanoff J.E., Richman B.W., Jones J.W. Disruption and infection of median sternotomy: a comprehensive review. Eur J Cardiothorac Surg 2002;21:831-839.[Abstract/Free Full Text]
14. Leal-Noval S.R., Rincon-Ferrari M.D., Garcia-Curiel A., et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery. Chest 2001;119:1461-1468.[Abstract/Free Full Text]
15. Backer C.L., Pensler J.M., Tobin G.R., Mavroudis C. Vascularized muscle flaps for life-threatening mediastinal wounds in children. Ann Thorac Surg 1994;57:797-802.[Abstract]
16. Erez E., Katz M., Sharoni E., et al. Pectoralis major muscle flap for deep sternal wound infections in neonates. Ann Thorac Surg 2000;69:572-577.[Abstract/Free Full Text]
17. Grant R.T., Breitbart A.S., Parnell V. Muscle flap reconstruction of pediatric poststernotomy wound infections. Ann Plast Surg 1997;38:365-370.[Medline]
18. Aeba R., Katogi T., Kawada S. Omental flap for mediastinitis after median sternotomy in asplenia syndrome and gut malrotation. Thorac Cardiov Surg 2000;48:243-244.
19. Julian O.C., Lopez-Belio M., Dye W.A., et al. The median sternotomy incision in cardiac surgery with extracorporeal circulation. Surgery 1957;42:753-761.[Medline]
20. Curtis J.J., Clark N.C., McKenney C.A., et al. Tracheostomy: a risk factor for mediastinitis after cardiac operation. Ann Thorac Surg 2001;72:731-734.[Abstract/Free Full Text]
21. Waldman J.D., Rosenthal A., Smith A.L., Shurin S., Nadas A.S. Sepsis and congenital asplenia. J Pediatr 1977;90:555-559.[Medline]
22. Biggar W.D., Ramirez R.A., Rose V. Congenital asplenia: immunologic assessment and a clinical review of eight surviving patients. Pediatrics 1981;67:548-551.[Abstract/Free Full Text]
23. Pollock E.M., Ford-Jones E.L., Rebeyka I., et al. Early nosocomial infections in pediatric cardiovascular surgery patients. Crit Care Med 1990;18:378-384.[Medline]
24. Harjula A., Jarvinen A. Postoperative median sternotomy dehiscence. Scand J Thorac Cardiovasc Surg 1983;17:277-281.[Medline]
25. Shafir R., Weiss J., Herman O., Cohen N., Stern D., Igra Y. Faulty sternotomy and complications after median sternotomy. J Thorac Cardiovasc Surg 1988;96:310-313.[Abstract]
26. Carrier M., Marchand R., Auger P., et al. Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit. J Thorac Cardiovasc Surg 2002;123:40-44.[Abstract/Free Full Text]
27. Gardlund B., Bitkover C.Y., Vaage J. Postoperative mediastinitis in cardiac surgery-microbiology and pathogenesis. Eur J Cardiothorac Surg 2002;21:825-830.[Abstract/Free Full Text]
28. Nakamura M.M., Rohling K.L., Shashaty M., Hongzhou L., Tang Y.W., Edwards K. Prevalence of methicillin-resistant Staphylococcus aureus nasal carriage in the community pediatric population. Pediatr Infect Dis J 2002;21:917-921.[Medline]
29. Sattler C.A., Mason E.O., Kaplan S.L. Prospective comparison of risk factors and demographic and clinical characteristics of community-acquired, methicillin-resistant versus methicillin-susceptible Staphylococcus aureus infection in children. Pediatr Infect Dis J 2002;21:910-916.[Medline]

This article has been cited by other articles:

				K. Ashour, K. Jamieson, and K. Lakhoo A sternotomy too far Interactive CardioVascular and Thoracic Surgery, October 1, 2009; 9(4): 753 - 754. [Abstract] [Full Text] [PDF]

				C. Anslot, S. Hulin, and Y. Durandy Postoperative Mediastinitis in Children: Improvement of Simple Primary Closed Drainage Ann. Thorac. Surg., August 1, 2007; 84(2): 423 - 428. [Abstract] [Full Text] [PDF]

				S. S. Shah, J. Kagen, E. Lautenbach, W. B. Bilker, J. Matro, T. E. Dominguez, S. Tabbutt, J. W. Gaynor, and L. M. Bell Bloodstream infections after median sternotomy at a children's hospital J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 435 - 440. [Abstract] [Full Text] [PDF]

				T. Fleck, P. Simon, G. Burda, E. Wolner, and G. Wollenek Vacuum assisted closure therapy for the treatment of sternal wound infections in neonates and small infants Interactive CardioVascular and Thoracic Surgery, June 1, 2006; 5(3): 285 - 288. [Abstract] [Full Text] [PDF]

				A. A. Al-Sehly, J. L. Robinson, B. E. Lee, G. Taylor, D. B. Ross, M. Robertson, and I. M. Rebeyka Pediatric Poststernotomy Mediastinitis Ann. Thorac. Surg., December 1, 2005; 80(6): 2314 - 2320. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): E. Dean McKenzie Charles D. Fraser Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tortoriello, T. A. Articles by Mott, A. R. Search for Related Content PubMed PubMed Citation Articles by Tortoriello, T. A. Articles by Mott, A. R. Related Collections Chest wall