maintenance of chest stability: further

Thorax (1971), 26, 424.

Maintenance of chest wall stability: a further report

B. T. LE ROUX and P. STEMMLER

The Thoracic Unit, Wentworth Hospital, Durban, and the Department of Surgery, University of Natal

The need to maintain stability of the chest wall with stainless steel strips in three unusual sets

of circumstances is explained. That 'flail' chest is not synonymous with 'stove-in' chest is madeclear.

Some of the problems which relate to the main-tenance of chest wall stability were discussed in aprevious paper (le Roux, 1964). In respect ofrestoration of rigidity of the chest wall after re-section of rib and sternal tumours, acrylic resinhas now been used in 58 patients. Rigidity has beeneffectively restored in all. In three cases, one illus-trated (Fig. 1 a-c), the prosthesis has had to beremoved after three months because of persistentinfection in relation to it. After removal of theprosthesis in these three patients, the chest wallwas stable and a further manoeuvre aimed atmaintenance of stability was not necessary.

In the previous paper on this subject, mentionwas made of the use of stainless steel struts tosupport the sternum after correction of pectusexcavatum (Paltia, Parkkalainen, Salamaa, andWallgren, 1959; Adkins and Blades, 1961 ; Jensen,Schmidt, and Garamella, 1962). There are com-mercially available steel struts (Jensen et al., 1962)made of specially annealed cold rolled alloy 302surgical stainless steel, in lengths which range from14 to 41 cm, and 12 to 14 mm in breadth. Threeunusual sets of circumstances made it necessaryto use similar struts', since techniques of main-tenance of chest wall stability previously describedwere thought likely to prove unsatisfactory.The purpose of this paper is to describe the

three cases in which stainless steel struts were usedto maintain chest wall stability.

CASE REPORTS

CASE 1 A woman of 28 years had a severe degree ofpectus excavatum. In addition there was a deepdepression in the left anterior chest wall, immediatelybelow an unusually small left breast. Mobilization ofthe sternum, resection of deformed costal cartilage,and dicing of deformed left ribs rendered the chestwall unstable, and the manoeuvre aimed at main-tenance of stability after correction of pectus exca-

'Made at short notice in the workshops at Wentworth Hospital,Durban, by Mr. S. S. Andrew

vatum usually employed (a Steinmann's pin laid acrossthe gap created by excision of deformed cartilage,deep to the sternum, and superficial to the lateral ribs)was inappropriate because of the instability of theleft lower ribs on which the pin would have neededto rest. A stainless steel strut, suitably curved, wasso placed, deep to the stemum and the mobilized leftchest wall, and superficial to right-sided ribs andunmolested left ribs, posteriorly, that the desiredshape of the thoracic cage was achieved, withstability. Convalescence was uneventful. An earlypostoperative radiograph is shown (Fig. 2). The strutwas a source of pain after 16 weeks. The left posteriorextremity of the strut was palpable deep to the skin,close to the long muscles of the back. Under localanaesthesia a small incision was made over the ex-tremity of the strut which was easily and painlesslydelivered, grasped in an artery forcep. The chest walldeformity remained corrected.

CASE 2 A labourer fell from the third floor of abuilding under construction, and landed with the leftlateral chest wall straddling a baulk of timber. Onadmission to hospital the patient was little disturbed.Beyond an almost total left traumatic thoracoplastyhe had few injuries, none more severe than bruisingwith abrasions. Remarkable was the absence of anyevidence of paradoxical movement of the left chestwall. A radiograph made on admission (Fig. 3) showsthe extent of traumatic thoracoplasty. That thispatient had a 'stove-in' chest is unquestionable, as isthe fact that he did not have a 'flail' chest. Surgicalmanagement was undertaken two days after injury,during which interval he had been entirely well,without evidence of embarrassment of respiration,and with normal blood gases. The purpose of anoperation was to correct the thoracoplastic deformitywhich was judged radiographically to be of an extentwhich' reduced by more than half the effective func-tion of the left lung.Through a left thoracotomy the inwardly displaced

ribs, all fractured in more than one place, were dis-impacted and mobilized. This manoeuvre convertedthe 'stove-in' chest to a 'flail' chest injury. Four stain-less steel struts, so shaped that they conformed withthe convexity of the left chest wall, were placedexternal to the ribs to which they were held by a

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Maintenance of chest wall -stability: a further report

number of interrupted silk sutures. An early post-operative radiograph is shown (Fig. 4). The left chestwall was stable from the time of recovery of con-sciousness at the end of the operation. Convalescencewas uneventful. The anterior ends of the two rostralsteel struts became easily palpable subcutaneouslyand were a source of pain. All four struts were re-moved six months after operation, through smallincisions in relation to the anterior ends of the strutsunder general anaesthesia. The struts, grasped in anartery forceps, slipped easily from their beds. The

chest wall has remained stable and the patient hasreturned to work. A chest radiograph made afterremoval of the struts is shown (Fig. 5).

CASE 3 A 17-year-old boy presented with an un-usually large tumour of the left chest wall (Fig. 6).At the apex of the tumour skin was invaded and abiopsy showed the lesion to be a chondrosarcoma.Through an elliptical incision, which skirted thelower border of the tumour, this was excised in-cluding most of the six related ribs. Although someskin had to be sacrificed because of tumour invasion,enough was left to cover the gap, so stretched hadthe skin become over the tumour. Posteriorly, ribswere excised medial to the costotransverse joint. Thelung was not invaded. So large was the resultant chest

(a)

.4

(C)

FIG. 1. Clinical photograph (a) shows an osteoclastomagrowing from the manubrium sterni, involving the medialends of both clavicles and the first and second costalcartilages of both sides. The tumour was excised; theosseous defect was repaired with acrylic and the cutaneousdefect with a skin flap; (b) preoperative chest radiograph;and (c) early postoperative chest radiograph. The acrylicwas secured to the clavicles with wire. The Michel clipsindicate the extent of the skin flap. There is a fluid levelin the early postoperative films. A boggy swelling per-sisted in relation to the acrylic. Fluid aspirated, althoughserious, was shown to contain staphylococci. The abscessin relation to the acrylic persisted and this was removedafter three months. The chest wall was, by this time,firm, and recovery was thereafter uneventful.(b)

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FIG. 2. Case 1. The stainless steel strip used to supportthe sternum and left lateral chest wall.

FIG. 3. Case 2. The extent of left traumatic thoracoplastyis shown.

wall deformity that there was not available sufficientacrylic resin to make a plate large enough to beeffective. Four steel struts were appropriately curvedand anchored anteriorly and posteriorly with silksutures. Marlex mesh was anchored by interruptedsilk sutures to the rib which constituted the rostral

FIG. 4. Case 2. An early postoperative radiograph of thepatient whose traumatic thoracoplasty was mobilized andsecured with stainless steel strips.

FIG. 5. Case 2. A radiograph after removal of the stain-less steel strips.

limit of the defect. The distal limit of the Marlexmesh was held taut and the steel struts were anchoredto the Marlex, in series, with interrupted silk. Thedistal limit of the mesh was then secured to thecaudal limit of the defect, and the mesh was similarlysecured anteriorly and posteriorly. In effect, the defect

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Maintenance of chest wall stability: a further report

FIG. 6. Case 3. The extent of the chest wall chondro-sarcoma is shown.

FIG. 8. Case 3. An early postoperative radiograph afterexcision of the chondrosarcoma and replacement of thechest wall with Marlex mesh and stainless steel strips.

was covered with a curtain of Marlex supported andgiven an appropriate contour to simulate the normallateral convexity of the thoracic cage by four stain-less steel struts. Convalescence was uneventful; thechest was stable throughout and the patient remainswell. A preoperative postero-anterior radiographand an early postoperative radiograph are shown(Figs. 7 and 8).

DISCUSSION

The unusual combination of pectus excavatumwith a deep depression of the left anterolateralchest wall in case 1 prevented the use of aSteinmann's pin to render stable the chest wallafter mobilization of the sternum. In case 2, 'stove-in' chest was converted to 'flail' chest at operation

A.% s to correct a severe degree of traumatic thoraco-plasty. Rather than manage surgically induced'flail' chest with intermittent positive pressureventilation in a patient pharmacologicallyrendered apnoeic, it was elected to achieve stabilitywith stainless steel struts, since a thoracotomy had

FIG. 7. Case 3. Preoperative anteroposterior radiograph already been made. The unusual size of the defectshowing extent of rib destruction from the chondrosarcoma in the chest wall, necessary for complete removalinvolving the left lateral and posterior chest wall. of a large tumour, in case 3, demanded the use of

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an alternative technique for maintenance of chestwall stability since insufficient acrylic resin wasavailable. Marlex is a polyethylene with a hightensile strength easily made into a monofilamentfrom which mesh can be made. It is said to exciteless foreign body reaction than, for example,Dacron, Orlon or nylon and is not rejected in thepresence of infection. It is available in two forms-a fine, pliable mesh (used in the operationdescribed) available in large sheets (10 x 14 in(25 4 x 35 6 cm) and called heavy gauge); and acoarser, more rigid mesh available in smallersheets (6 x 6 in (1 52 x 15 2 cm) and called trachealmesh). A sheet of Marlex. stretched tautly. tocover the gap in the chest wall in this patient wasjudged unlikely alone to prevent paradox in early

convalescence, and would have resulted in a cos-

metically poor result because of the inevitableflattening of the chest. The steel struts contributedto security and restored the convexity of the chestwall.

REFERENCESAdkins, P. C., and Blades, B. (1961). A stainless steel strut

for correction of pectus excavatum. Surg. Gynec.Obstet., 113, 111.

Jensen, N. K., Schmidt, W. R., and Garamella, T. J. (1962).Funnel chest: a new corrective procedure. J. thoracSurg., 43, 731.

le Roux, B. T. (1964). Maintenance of chest wall stability.Thorax, 19, 397.

Paltia, V., Parkkalainen, K. V., Salamaa, M., and Wallgren,G. R. (1959). Operative technique in funnel chest. Ex-perience in 81 cases. Acta chir. scand., 116, 90.

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