Chest Wall Reconstruction

and Rib Fixation

Daniel L Miller MD

Chief, General Thoracic Surgery

Emory University Healthcare

The Kamal A Mansour Professor of Surgery

Emory University School of Medicine

Atlanta, Georgia USA

Chest Wall Resection/Reconstruction

• Multidisciplinary approach – Individualize patient

– Thoracic skeleton

– Soft tissue

– Critical care

• Etiological factors – Tumor

• Primary

• Metastasis

• Recurrent

– Radiation

– Trauma

– Infection

Chest Wall Reconstruction

1. Pleural cavity

2. Skeletal support

3. Soft tissue coverage

4. Postoperative critical care

Chest Wall Reconstruction

• Pleural cavity

– Pleural drainage

• air tight

– Muscle flap transposition

– Omentum transfer

– Pneumoperitoneum

– Thoracoplasty

– Eloesser flap

– Diaphragm reconstruction

Chest Wall Reconstruction

• Skeletal support – Fascia lata

– Bone (Rib graft)

– Teflon

– Silicone

– Mesh • PTFE

• Prolene

• Marlex

• Vicryl

– Methyl methacrylate sandwich

– Struts – PLA and titanium

– Bovine pericardium (Veritas)

– Alloderm

Chest Wall Reconstruction

Thoracic Skeleton

• Defects four contiguous ribs or greater

than 5 centimeters (The Rule)

– Chest wall stabilization (paradoxical motion)

– Protect vital organs

• May not need to reconstruct larger defects

if previous radiation therapy (Exception)

• Posterior defects are well tolerated

– Posterior ribs 1 – 3 (4) – Hinge point

– Scapula protection (Exception)

Osteogenic Sarcoma of Chest Wall

Neoadjuvant Chemotherapy

Margins of Resection (>4 cm)

Chest Wall Reconstruction

Polypropylene vs PTFE Mesh

• Operator dependent

• Polypropylene more

difficult to stretch

without wrinkles

• PTFE is watertight,

easier to handle

• Mayo Clinic

experience showed

little difference *

J Thorac Cardiovasc Surg 1999

Angiosarcoma Wide Resection

Sternum and Costal Cartilages

Radiation-induced Angiosarcoma Sternum

Sternal Reconstruction

Anterior Chest Wall Reconstruction

Methyl Methacrylate / Mesh Sandwich

• Prevention of

paradoxical

respiration

• Improved chest

contour

• Treatment of choice

for large skeletal

defects in many

institutions

Multiple Reconstruction Products PTFE and Methyl Methacrylate Sandwich

Chest Wall Reconstruction

Methyl Methacrylate / Mesh Sandwich

• Non-randomized study comparing methyl

methacrylate and PTFE

Methyl

methacrylate PTFE

Morbidity 5.2% (2/38) 24% (5/21)

Paradoxical

respiration 2.6% (1/38) 24% (5/21)

Journal Invest Surg 2006

Bovine Pericardium

Bovine Pericardium

Acellular Dermal Matrix

Acellular Dermal Matrix

• Potential use in contaminated fields

• Experimental data shows greater implant-

defect interface strength than PTFE at 4

weeks *

• Little long term clinical data

– Tensile strength

– Lung herniation

– Paradoxical chest wall motion

* Plast Reconstr Surg 2007

Chest Wall Reconstruction:

Soft Tissue Reconstruction – Muscle flaps

Chest Wall Reconstruction:

Soft Tissue Reconstruction

• Pectoralis major

• Latissimus dorsi

• Rectus abdominis

• Omentum

• Serratus anterior

• Free flaps: rectus abdominis, latissimus

• Thoracoepigastric skin flaps

Pedicled flaps

Bilateral Pectoralis Major Flaps

Recurrent Sarcoma Chest Wall

Acellular Dermal Matrix

Plastic Reconstr Surg 2004

Acellular Dermal Matrix

Latissimus Flap Coverage

Forequarter Amputation Chest Wall and Arm Removal

1..

Methyl Methacrylate Reconstruction

1..

Deltocervical Tissue Flap

1..

Infected Chest Wall Radiation Necrosis

Recurrent Cancer

Soft Tissue infection

Osteomyelitis

Radiation-induced Angiosarcoma Sternum

Titanium Struts Reconstruction

Radiation-induced Angiosarcoma Sternum

Bovine Pericardium (Veritas)

Radiation-induced Angiosarcoma Sternum

Postoperative CXR

Chest Wall Reconstruction

Poly Lactic Acid Bovine Pericardium

Sternal Reconstruction

Sternal Reconstruction

Sternal Reconstruction

Rib Defect Reconstruction

Rib Defect Reconstruction

BioBridge (PDS)

Rib Defect Reconstruction

Flail Chest

• Thoracic Trauma is seen in 20% of all trauma

• TT is cause of death in 25% of trauma cases

• Over 50% of the TT is rib fractures

• 1/13 pts (8%) have a flail chest

• Definition: More than 2 continuous rib fractures

at two separate sites

– Pulmonary Contusion

– Hemopneumthorax

– Associated injuries

Flail Chest

• Paradoxical motion (External)

• Pulmonary contusion

• Severe pleurtic pain

• Decreased tidal volume

• Alveoli collapse

• Arteriovenous shunting

• Hypoxemia

• Respiratory insufficiency

Flail Chest

Treatment

• Pain control – Narcotics, NSAIDs, Intercostal blocks, Epidural

catheter

• Aggressive physiotherapy (FOB)

• Careful fluid administration

• Pulmonary support (Internal stabilization)

– Intubation

– BIPAP

Flail Chest

Treatment

• Chest wall stability

• External stability (historical)

• Rib fixation (Limited size 8 – 12 mm, Thin

cortex, Continued movement)

– K wires (intramedullary)

– Anterior metal plating

– Locking systems (metal)

– Absorbable plates

Flail Chest Indications

• Flail chest

– Failure to wean

– Paradoxical motion weaning

– No pulmonary contusion

• Reduction of pain and disability

– Painful movable rib

– Failure of narcotics/epidural

– Fracture movement worsens pain

– Minimal associated injuries (ISS)

• Chest wall deformity

– Loss of chest wall integrity (crush injury)

• Non-Union rib fracture (> 2 months)

• Other thoracic surgery required

79 yo W fell 5 days ago (PD)

Presented to ER with SOB and CP

CT Scan – Displaced Rib Fracture

CT Scan – Displaced Rib Fracture

and Hemothorax

CT Scan - Hemothorax

CT Scan – Pulmonary Contusion

Repair Rib Fracture

Rib Loc System

S/P Rib Fracture Repair

Rib Loc times 2

Drainage Hemothorax (500cc)

Sternal Plating

Primary Sternal Plating

• Rigid plate fixation in 45 high risk patients

• Matched control group of 207 patients

• Mediastinal infection

– Control group 14.8%

– Rigid fixation group 0%

Eur J of Card Thor Surgery 2004

CW Reconstruction and Rib Fixation

• Thoracic skeleton reconstruction

– Small defects no reconstruction or mesh

– Large defects MMS, PTFE or TT struts

• Soft tissue reconstruction

– Small defects: latissimus dorsi or pectoralis

– Large defects: rectus abdominis, possible free flap

• Location and etiology is most important

• New chest wall product stabilization are

promising

Summary

• Keys to success in these complex cases:

– Total resection of the disease process

– Reconstruction of chest wall integrity

– Soft tissue coverage

• Team of physicians well versed in:

– Chest wall resection and reconstruction

• Prosthetic materials

– Free or pedicle flaps

– Critical care of the patient

Conclusions

• Chest wall reconstruction and rib fixation is

both safe and effective

• Each patient should be individualized

– Review old operative reports

– Review previous treatments regiments

– Life expectancy

– Quality of life

• Earlier treatment in warranted

• Team approach is mandatory