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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
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Chest Wall Resection/Reconstruction
• Multidisciplinary approach – Individualize patient
– Thoracic skeleton
– Soft tissue
– Critical care
• Etiological factors – Tumor
• Primary
• Metastasis
• Recurrent
– Radiation
– Trauma
– Infection
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Chest Wall Reconstruction
1. Pleural cavity
2. Skeletal support
3. Soft tissue coverage
4. Postoperative critical care
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Chest Wall Reconstruction
• Pleural cavity
– Pleural drainage
• air tight
– Muscle flap transposition
– Omentum transfer
– Pneumoperitoneum
– Thoracoplasty
– Eloesser flap
– Diaphragm reconstruction
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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
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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)
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Osteogenic Sarcoma of Chest Wall
Neoadjuvant Chemotherapy
Margins of Resection (>4 cm)
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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
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Angiosarcoma Wide Resection
Sternum and Costal Cartilages
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Radiation-induced Angiosarcoma Sternum
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Sternal Reconstruction
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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
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Multiple Reconstruction Products PTFE and Methyl Methacrylate Sandwich
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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
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Bovine Pericardium
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Bovine Pericardium
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Acellular Dermal Matrix
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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
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Chest Wall Reconstruction:
Soft Tissue Reconstruction – Muscle flaps
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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
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Bilateral Pectoralis Major Flaps
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Recurrent Sarcoma Chest Wall
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Acellular Dermal Matrix
Plastic Reconstr Surg 2004
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Acellular Dermal Matrix
Latissimus Flap Coverage
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Forequarter Amputation Chest Wall and Arm Removal
1..
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Methyl Methacrylate Reconstruction
1..
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Deltocervical Tissue Flap
1..
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Infected Chest Wall Radiation Necrosis
Recurrent Cancer
Soft Tissue infection
Osteomyelitis
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Radiation-induced Angiosarcoma Sternum
Titanium Struts Reconstruction
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Radiation-induced Angiosarcoma Sternum
Bovine Pericardium (Veritas)
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Radiation-induced Angiosarcoma Sternum
Postoperative CXR
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Chest Wall Reconstruction
Poly Lactic Acid Bovine Pericardium
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Sternal Reconstruction
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Sternal Reconstruction
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Sternal Reconstruction
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Rib Defect Reconstruction
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Rib Defect Reconstruction
BioBridge (PDS)
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Rib Defect Reconstruction
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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
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Flail Chest
• Paradoxical motion (External)
• Pulmonary contusion
• Severe pleurtic pain
• Decreased tidal volume
• Alveoli collapse
• Arteriovenous shunting
• Hypoxemia
• Respiratory insufficiency
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Flail Chest
Treatment
• Pain control – Narcotics, NSAIDs, Intercostal blocks, Epidural
catheter
• Aggressive physiotherapy (FOB)
• Careful fluid administration
• Pulmonary support (Internal stabilization)
– Intubation
– BIPAP
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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
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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
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79 yo W fell 5 days ago (PD)
Presented to ER with SOB and CP
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CT Scan – Displaced Rib Fracture
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CT Scan – Displaced Rib Fracture
and Hemothorax
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CT Scan - Hemothorax
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CT Scan – Pulmonary Contusion
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Repair Rib Fracture
Rib Loc System
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S/P Rib Fracture Repair
Rib Loc times 2
Drainage Hemothorax (500cc)
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Sternal Plating
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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
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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
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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
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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