Ann Thorac Surg 2006;82:332-334
© 2006 The Society of Thoracic Surgeons
Case report
Oklahoma Prosthesis: Resection of Tumor of Clavicle and Chest Wall Reconstructed With a Custom Composite Graft
Shant M. Vartanian, MD
a
,
Shanthi Colaco, MD
b
,
Lisa E. Orloff, MD
b
,
Pierre R. Theodore, MD
a
,
*
a Division of Cardiothoracic Surgery, University of California, San Francisco, California
b Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California
Accepted for publication September 14, 2005.
* Address correspondence to Dr Theodore, University of California at San Francisco, 1600 Divisadero St, Box 1674/MZ Room A-745, San Francisco, CA 94143-1674 (Email: theodorep{at}surgery.ucsf.edu).
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Abstract
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Tumors involving the clavicle by primary or metastatic growth may require clavicular resection often with rib resection. The resulting cosmetic and functional impairment of clavicular resection may be significant with a sloped appearing shoulder girdle and chronically impaired movement of the upper extremity. We report a 48-year-old woman presenting with a bulky metastatic renal cell mass of her left clavicle extending to the chest wall. We report en-bloc clavilculectomy and chest wall resection with a novel method of reconstruction using a single methyl methacrylate and prolene composite prosthesis in a configuration resembling the state of Oklahoma.
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Introduction
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Clavicle resections are often necessary during anterior approaches to the chest in thoracic and vascular surgery. Although claviculectomy is tolerated, biomechanical and clinical evidence have recognized the frequent sequelae of shoulder girdle instability with subsequent weakness and pain after these procedures [1, 2]. Literary descriptions of clavicle reconstruction frequently involve complex vascularized flaps or hardware reconstructions [3, 4]. We report a simple method of composite clavicle and chest wall reconstruction with a good functional postoperative result.
A 48-year-old woman with a history of a radical nephrectomy for renal cell carcinoma presented 1 year after resection with a large, bulky metastasis involving the medial third of the clavicle, extending to the manubrium and the anterior portion of the first rib. A preoperative computed tomographic scan demonstrated chest wall invasion and compression of the subclavian vein (Fig 1). The patient underwent preoperative angiography and coil embolization of multiple large feeding vessels from the subclavian and internal thoracic artery.
The resection was performed through a cervicothoracic incision as described by Dartevelle and colleagues [5] along the anterior border of the left sternocleidomastoid muscle and immediately inferior to the left clavicle (Fig 2). The manubrium was divided to just inferior of the first rib articulation. Without violating the capsule of the mass, the tumor was freed from the remaining soft tissue structures of the neck. The subclavian vein was spared. The thryrocervical trunk artery and the external and anterior jugular veins were ligated and divided. After en-bloc resection of the clavicle, the lateral manubrium, and the first rib, the remaining chest wall defect measured 6 x 5 cm, and the resected left clavicle measured 12 cm in length. The defect was reconstructed with a sandwich of prolene mesh surrounding methyl methacrylate and was fashioned to reconstruct the chest wall and the clavicular defects.
After measuring and sketching the shape of the planned prosthesis, a sandwich of prolene mesh was fashioned. The medial 
of the prosthesis was made flat and the lateral was rolled into a cylinder to serve as the extension to the acromioclavicular joint. Methyl methacrylate (4 g) (Howmedica Osteonics, Mahwah, NJ) was introduced between the layers of the prolene mesh and within the cylindrical prolene mesh extension. After hardening, the prosthesis resembled the state of Oklahoma with the panhandle extending to the location of the acromioclavicular joint (Fig 3). The pectoralis major muscle was harvested on its lateral pedicle to place under the clavicular extension of the prosthesis for protection of the subclavian vessels. The mesh was secured into place with nonabsorbable monofilament suture placed through the residual manubrium, around the first rib, and through the cut edge of the distal clavicle, which provided a secure and immobile reconstruction of the chest wall and clavicle (Fig 4). The subcutaneous tissue was closed in layers over the prosthesis after placement of two superficial drains and one chest tube. No skin was resected and the wound was primarily closed. The postoperative result revealed normal contour of the acromioclavicular joint with good range of motion at the shoulder (Fig 5).
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Comment
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The clavicle plays an understated but important role in the function of the shoulder. Anatomically, in addition to providing protection to the underlying subclavian vessels and brachial plexus, the clavicle imparts a mechanical advantage to the shoulder girdle by stabilizing the scapula and serving as a point for muscular origination and insertion [6]. In patients with a congenital absence of the clavicle, normal function is observed, presumably the result of a lifetime of muscular adaptation [7]. However, in adult patients with surgical resection of the clavicle, shoulder instability may result with subsequent weakness, pain, and brachial plexus neuropathy [1, 2, 8]. Although few clinical studies have explicitly investigated this issue, it is clear that a sizable proportion of patients experience significant symptoms, particularly with repetitive motion or strenuous activity. Some patients also find the subsequent soft tissue defect and asymmetrically sloped shoulder cosmetically unappealing.
Despite this, reconstruction rarely follows claviculectomy. Descriptions of clavicle reconstructions involve complex tissue transfer procedures, most commonly from the first rib or from the fibula. We report a simple method of reconstructing the clavicle with a methyl methacrylate and prolene composite graft. The surgical technique used in this case is a natural extension of chest wall reconstructions with composite grafts applied to the clavicle. The result is a simple and quick technique that effectively stabilizes the acromioclavicular joint while also preserving the cosmesis of the clavicle and shoulder girdle.
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References
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Abstract
Introduction
