Thoracic Cage Deformity Correction in Patients with Lenke Type 1 Adolescent Idiopathic Scoliosis.

Whether the thoracic cage deformity in adolescent idiopathic scoliosis (AIS) can be sufficiently treated with vertebral derotation alone, has been quite controversial. Our aim is to control the hypothesis that the rib cage deformity (RCD) may be adequately corrected when only vertebral derotation is applied. We studied retrospectively patients treated for AIS with posterior spinal fusion without costoplasty. The RCD was assessed on lateral radiographs by rib index (RI). The correction of RI after surgery was calculated. Of the 103 patients that were finally included in our study, 29 patients (22 females and 7 males; mean age, 14.5 ± 2.1 years) represented Group A (Harrington rod instrumentation - no derotation), while 74 patients (61 females and 13 males; mean age, 14.1 ± 2.4 years) were operated with either a full pedicle screw system or a hybrid construct with hooks and pedicle screws (Group B-derotation). RI was significantly corrected after surgery in both groups. RI was significantly greater in Group A after surgery. Whatsoever, the correction of RI, thereby the RCD correction, did not significantly differ among groups. In conclusion, it cannot be suggested by the present study that vertebral derotation alone can offer an absolute correction of the deformity of the thoracic cage in patients with Lenke Type 1 AIS, and it seems also that the development of RCD may not exclusively result from the spinal deformity, thus questions can be further raised regarding scoliogeny per se.

Effect of thoracic cage width on surgery time and postoperative outcome in minimally invasive esophagectomy.

INTRODUCTION: Minimally invasive esophagectomy (MIE) for esophageal cancer is a complex procedure that reduces postoperative morbidity in comparison to open approach. In this study, thoracic cage width as a factor to predict surgical difficulty in MIE was evaluated. METHODS: All patients of our institution receiving either total MIE or robotic-assisted MIE (RAMIE) with intrathoracic anastomosis between February 2016 and April 2021 for esophageal cancer were included in this study. Right unilateral thoracic cage width on the level of vena azygos crossing the esophagus was measured by the horizontal distance between the esophagus and parietal pleura on preoperative computer tomography. Patients' data as well as operative and postoperative details were collected in a prospective database. Correlation between thoracic cage width with duration of the thoracic procedure and postoperative complication rates was analyzed. RESULTS: Overall, 313 patients were eligible for this study. Thoracic width on vena azygos level ranged from 85 to 149 mm with a mean of 116.5 mm. In univariate analysis, a small thoracic width significantly correlated with longer duration of the thoracic procedure (p = 0.014). In multivariate analysis, small thoracic width and neoadjuvant therapy were identified as independent factors for long duration of the thoracic procedure (p = 0.006). Regarding postoperative complications, thoracic cage width was a significant risk factor for occurrence of postoperative pneumonia in the multivariate analysis (p = 0.045). Dividing the cohort into two groups of patients with narrow (≤ 107 mm, 19.5%) and wide thoraces (≥ 108 mm, 80.5%), the thoracic procedure was significantly prolonged by 17 min (204 min vs. 221 min, p = 0.014). CONCLUSION: A small thoracic cage width is significantly correlated with longer operation time during thoracic phase of a MIE in Europe, which suggests increased surgical difficulty. Patients with small thoracic cage width may preferably be operated by MIE-experienced surgeons.

Costal margin injuries and trans-diaphragmatic intercostal hernia: Presentation, management and outcomes according to the Sheffield classification.

BACKGROUND: Costal margin rupture (CMR) injuries are under-diagnosed and inconsistently managed, while carrying significant symptomatic burden. We hypothesized that the Sheffield Classification system of CMR injuries would relate to injury patterns and management options. METHODS: Data were collected prospectively between 2006 and 2023 at a major trauma center in the United Kingdom. Computed tomography scans were interrogated and injuries were categorized according to the Sheffield Classification. Clinical, radiologic, management and outcome variables were assessed. RESULTS: Fifty-four patients were included in the study. Intercostal hernia (IH) was present in 30 patients and associated with delayed presentation ( p = 0.004), expulsive mechanism of injury (i.e. such as occurs with coughing, sneezing, or retching), higher body mass index ( p < 0.001), and surgical management ( p = 0.02). There was a bimodal distribution of the level of the costal margin rupture, with IH Present and expulsive mechanism injuries occurring predominantly at the ninth costal cartilage, and IH Absent cases and other mechanisms at the seventh costal cartilage ( p < 0.001). There were correlations between the costal cartilage being thin at the site of the CMR and the presence of IH and expulsive etiology ( p < 0.001). Management was conservative in 23 and surgical in 31 cases. Extrathoracic mesh IH repairs were performed in 3, Double Layer Mesh Repairs in 8, Suture IH repairs in 5, CMR plating in 8, CMR sutures in 2, and associated Surgical Stabilization of Rib Fractures in 11 patients. There was one postoperative death. There were seven repeat surgical procedures in five patients. CONCLUSION: The Sheffield Classification is associated statistically with presentation, related chest wall injury patterns, and type of definitive management. Further collaborative data collection is required to determine the optimal management strategies. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Efficacy of ultrasound-guided bilateral costal margin block in laparoscopy-assisted gastrectomy: A double-blind randomized trial.

BACKGROUND: Ultrasound-guided costal margin block (CMB) is a superficial and easily applicable technique. The current study aims to investigate its analgesic efficacy in patients undergoing laparoscopy-assisted gastrectomy and describe its feasibility. METHODS: Forty-two patients undergoing laparoscopy-assisted gastrectomy were enrolled in this prospective, double-blind, randomized clinical trial. Patients were randomized to receive standard general anesthesia with (block group, n = 21) or without (control group, n = 21) ultrasound-guided bilateral CMB. The primary outcome was 24-h intravenous morphine equivalents after surgery. Secondary outcomes included consumption of titrated morphine, 24-48 h morphine equivalents, consumption of intraoperative remifentanil, numerical pain rating scale scores, time to first opioid dose, patient satisfaction, adverse effects, and recovery events. RESULTS: The postoperative 24-h morphine equivalents in the block group were significantly reduced compared to the control group (14.4 ± 7.4 mg vs. 29.9 ± 9.8 mg, p < 0.001). Both the titrated morphine consumption in the post-anesthesia care unit (PACU) and intraoperative remifentanil consumption were lower in the block group than in the control group. Patients in the block group had relatively lower average pain scores in PACU and reported more satisfaction with pain relief. Adverse effects and hospital length of stay after surgery were comparable between the two groups (p > 0.05). CONCLUSION: As a novel and easily-performed technique, ultrasound-guided bilateral CMB can reduce opioid consumption in patients undergoing laparoscopy-assisted gastrectomy.

Conventional chondrosarcoma of the rib cage and sternum: clinicopathological and molecular analysis of 27 patients treated at a single institution.

Conventional chondrosarcoma of the chest wall is rare, accounting for 15% of cases. Our purpose was to document clinicopathological, imaging and outcome results from a novel set of chest wall chondrosarcomas, and to analyze for IDH mutations and novel molecular alterations. Gross and microscopic pathology, imaging and clinical charts were reviewed. Targeted next-generation sequencing was performed to identify somatic mutations and copy number alterations. The cohort consisted of 27 patients: 16 men and 11 women (mean age 51 years; range 23-76). Palpable mass was the most common presentation. Five were discovered incidentally. Among 20 tumors with complete imaging, 15 arose from a rib and 5 from the sternum. Seven rib tumors were central/intramedullary, 5 were periosteal, 2 were secondary peripheral chondrosarcomas, and one was indeterminate. Among sternal tumors, 4 were central/intramedullary and one was periosteal. Half the periosteal tumors arose from the costochondral junctional cartilage (CCJ). Periosteal chondrosarcomas were sometimes mistaken for extraskeletal masses on initial clinical or radiological examinations. Fifty-nine percent of all tumors were grade 1 and 41% were grade 2. None were dedifferentiated chondrosarcomas. Heterozygous IDH1 mutation was detected in one tumor and heterozygous RAD50 mutation in another. Local recurrence(s) happened in 41% and metastasis in 41%. Grade had strong association with local recurrence (25% grade 1 vs. 64% grade 2 [P = .0447]), metastatic recurrence (19% grade 1 vs. 73% grade 2 [P = .0058]), and survival. Although chest wall chondrosarcomas share morphologic and molecular features with other chondrosarcomas, there is a much higher incidence of periosteal chondrosarcomas. IDH mutant tumors are uncommon. Early diagnosis and margin-negative resection is treatment of choice since chondrosarcomas are chemo- and radioresistant.

Experience of the Wang procedure in treating pectus excavatum in two hundred fifty-six paediatric patients.

INTRODUCTION: To analyze and summarize the orthopaedic effect and application experience of the Wang procedure in the treatment of pectus excavatum in paediatric patients. METHODS: The clinical data of 256 children ranging from 0.83~14 years (4.89±2.83 years) who underwent the Wang procedure for pectus excavatum from January 2017 to September 2020 in our hospital were analyzed retrospectively. A 1~2-cm incision was made in front of the xiphoid, and a tunnel was constructed on the deep surface of the thoracic cage. Steel wires were inserted through the bilateral costal arch and the lower sternum, and a steel bar was placed in the tunnel. The wires were pulled taut and fixed to the bar, and the incision was sutured. RESULTS: All the procedures were performed using one steel bar. The range of the procedure duration, the intra-operative bleeding volume, and the hospitalization stays of the patients were 18 to 45 (24.02±4.89) minutes, one to ten (2.16±1.68) mL, and three to nine days (5.71±1.35 days) respectively. Post-operative pneumothorax occurred in three cases without other complications. All the cases received follow-up for one to 45 months after discharge, during which six cases experienced poor wound healing, removed steel plate in 82 cases, and three cases of pectus excavatum recurrence. CONCLUSIONS: The Wang procedure is a good option for treating pectus excavatum, secondary pectus excavatum, or recurrent pectus excavatum in paediatric patients.

Tuberculosis of the ribcage by dissemination of Koch bacilli.

INTRODUCTION: Tuberculosis (TB) is an infectious, transmissible and immune disease caused by the Mycobacterium tuberculosis-complex (MTBC). Although osteoarticular tuberculosis (OATB) has been widely described, the ribcage variety remains a rare form. CASE REPORT: A thirteen-month-old male and a twenty-month-old female, both with pain and increased volume of anterolateral left rib cage were described. Physical examination revealed the presence of a soft consistent mass at the level of the 9th and 5th costal arches in the male and female patients respectively. Upon clinical evaluation, tuberculosis was suspected, which was confirmed by X-ray and histopathological studies. After confirmation, the management, based on anti-tuberculosis therapy was started as follows: nine months of anti-tuberculosis therapy for the male patient and fourteen months for the female. The outcomes were favorable for both patients. However, further interventions, consisting of abscess drainage in the male patient and excisional biopsy in the female patient were necessary. With these therapeutic interventions, to date, the patients are without any evidence of active TB.

Thoracic cavity-to-cage ratio is a predictor of technical difficulties in minimally invasive esophagectomy.

BACKGROUND: Technical difficulties are occasionally encountered when performing conventional minimally invasive esophagectomy and robot-assisted minimally invasive esophagectomy in patients with a narrow thoracic cavity. Thoracic cavity-to-cage ratio is an indicator of thoracic cavity length. We hypothesized that the thoracic cavity-to-cage ratio could be a predictor of technical difficulties in conventional minimally invasive esophagectomy and robot-assisted minimally invasive esophagectomy. METHODS: We evaluated 340 patients who underwent minimally invasive esophagectomy for esophageal squamous cell carcinoma between April 2010 and March 2021. Thoracic cavity-to-cage ratio was calculated as the diameter of the thoracic cavity to that of the thoracic cage at the brachiocephalic vein, tracheal bifurcation, and inferior right pulmonary vein levels. Moreover, thoracic cavity-to-cage ratio score, which is an indicator of the whole thoracic cavity length based on the thoracic cavity-to-cage ratio at the 3 levels, was defined. The thoracic procedure time was considered an indicator of surgical difficulty. RESULTS: We divided the patients into the conventional minimally invasive esophagectomy (n = 295) and robot-assisted minimally invasive esophagectomy (n = 45) groups. The patients in each group were divided into 2 cohorts according to median thoracic procedure time. Based on multivariate analysis, body mass index (P = .0007), clinical N stage (P = .0191), and thoracic cavity-to-cage ratio score (P = .0005) were independent factors for thoracic procedure time in the conventional minimally invasive esophagectomy group. Moreover, thoracic cavity-to-cage ratio at the tracheal bifurcation level (P = .0331) was the only independent factor for thoracic procedure time in the robot-assisted minimally invasive esophagectomy group. CONCLUSION: Thoracic cavity-to-cage ratio could be a predictor of technical difficulties in both conventional minimally invasive esophagectomy and robot-assisted minimally invasive esophagectomy.

Postoperative changes in rib cage deviation in adolescent idiopathic scoliosis.

BACKGROUND: Scoliosis causes changes in the thorax, but it is unclear what type of changes occur in the thoracic profile after scoliosis surgery. OBJECTIVE: To investigate changes in rib cage deviation in the postoperative period after adolescent idiopathic scoliosis (AIS) surgery. METHODS: Forty-four patients with AIS with a main right thoracic curvature underwent posterior surgical fusion (PSF), and radiological parameters of the spine and thorax were evaluated. RESULTS: The correction rates of main thoracic curve (MT)-Cobb angle at immediate after surgery and postoperative follow-up (2 years) were 64% and 66%, respectively. At these two postoperative time points, the correction rates of height of thoracic vertebrae 1 to 12 (T1T12) were 10% and 12%; the correction rates of Rib-vertebra angle difference (RVAD) were 59% and 52%; the correction rates of Apical rib hump prominence (RH) were 58% and 76%; while the correction rates of Apical vertebral body-rib ratio (AVB-R) were 23% and 25%, respectively. Statistical analysis showed that all these radiological parameters at the two postoperative time points were significantly different from the preoperative values (p< 0.001). There were significant correlations between MT-Cobb angle and T1-T12 height (p< 0.001), RVAD (p< 0.001), RH (p< 0.001), and AVB-R (p< 0.001). CONCLUSIONS: Posterior spinal fusion appears to be effective at correcting scoliosis, and the correction of rib cage deviation also plays an important role.

Estimating pulmonary function after surgery for adolescent idiopathic scoliosis using biplanar radiographs of the chest with 3D reconstruction.

AIMS: This study addressed two questions: first, does surgical correction of an idiopathic scoliosis increase the volume of the rib cage, and second, is it possible to evaluate the change in lung function after corrective surgery for adolescent idiopathic scoliosis (AIS) using biplanar radiographs of the ribcage with 3D reconstruction? METHODS: A total of 45 patients with a thoracic AIS which needed surgical correction and fusion were included in a prospective study. All patients underwent pulmonary function testing (PFT) and low-dose biplanar radiographs both preoperatively and one year after surgery. The following measurements were recorded: forced vital capacity (FVC), slow vital capacity (SVC), and total lung capacity (TLC). Rib cage volume (RCV), maximum rib hump, main thoracic curve Cobb angle (MCCA), medial-lateral and anteroposterior diameter, and T4-T12 kyphosis were calculated from 3D reconstructions of the biplanar radiographs. RESULTS: All spinal and thoracic measurements improved significantly after surgery (p < 0.001). RCV increased from 4.9 l (SD 1) preoperatively to 5.3 l (SD 0.9) (p < 0.001) while TLC increased from 4.1 l (SD 0.9) preoperatively to 4.3 l (SD 0.8) (p < 0.001). RCV was correlated with all functional indexes before and after correction of the deformity. Improvement in RCV was weakly correlated with correction of the mean thoracic Cobb angle (p = 0.006). The difference in TLC was significantly correlated with changes in RCV (p = 0.041). It was possible to predict postoperative TLC from the postoperative RCV. CONCLUSION: 3D rib cage assessment from biplanar radiographs could be a minimally invasive method of estimating pulmonary function before and after spinal fusion in patients with an AIS. The 3D RCV reflects virtual chest capacity and hence pulmonary function in this group of patients. Cite this article: Bone Joint J 2022;104-B(1):112-119.

Association between intra-operative hemodynamic changes and corrective procedures during posterior spinal fusion in adolescent patients with scoliosis: A case-control study.

ABSTRACT: Previous reports indicated that a decrease in intra-operative cardiac output and mean arterial pressure occurs due to thoracic cage deformities when patients with scoliosis are placed in the prone position. The aims of this study were to investigate the occurrence of hypotension during posterior spinal fusion in adolescent patients with scoliosis, and the association between hypotension, surgical procedures, changes of thoracic cage morphology.This retrospective, single-center, case-control study included 106 patients who underwent surgeries for spinal deformity at our institute between June 2014 and March 2020. The inclusion criteria were: age ≤19 years at the time of surgery, lowest instrumented vertebra over L5, posterior spinal fusion as the first surgery for scoliosis, and no severe cardiac or pulmonary disease pre-operatively. Finally, 49 patients met the criteria, and were divided to 3 groups as follows: thoracic constructive curve using a 6.0-mm cobalt-chromium alloy circular rod (T-C group; n = 28); thoracolumbar/lumbar constructive curve using a 6.0-mm cobalt-chromium alloy circular rod (L-C group; n = 8); and thoracic constructive curve using a 5.5-mm cobalt-chromium alloy beam-like rod (T-B group; n = 13). The beam-like rod is characteristic as the rod is mounted to screw heads without cantilever force. Intra-operative changes in circulation associated with corrective procedures, perioperative data, and sagittal depth and sternum deviation of thoracic cage were compared between the 3 groups.The T-C group had a higher rate of hypotension alarm than did the other groups (7 vs 0 vs 0; P = .047). Corrective procedures included rodding 4 times, rod rotation maneuver once, and direct vertebral rotation twice. Blood pressure was increased by pausing the correction procedures, increasing infusion, and administering vasopressors. The T-C and T-B groups had greater sternum deviation parameters than the L-C group, both before and after surgery. All parameters associated with sagittal depth and sternum deviation decreased significantly after surgery in the T-C and the T-B groups.In corrective surgery for constructive thoracic scoliosis, the corrective procedures requiring the application of compression force in the forward direction should be closely monitored in view of their possible influence on circulatory conditions.

Abdominal intercostal hernia and costal arch repair.

A 70-year-old asthmatic man presented with a history of chronic intermittent left-sided chest pains and a bulge-like deformity of his chest which became more prominent with expiration. He sustained a traumatic fall 2 years prior whereby he fractured his right humerus at the surgical neck, requiring total arthroplasty. Examination and CT imaging of the thorax revealed a left costal arch fracture with hemidiaphragm rupture and associated transperitoneal fat herniation. He underwent left thoracolaparotomy with costal arch and diaphragmatic hernia repair. He was discharged 48 hours postoperatively and is satisfied with good outcomes under initial follow-up. This case report highlights the surgical management of a condition that usually presents late after significant trauma and may progress to visceral strangulation if untreated.

Intrathoracic rib: rare rib anomaly, review of the literature and proposal for classification.

Background: Intrathoracic ribs are very rare congenital anomalies, and often discovered incidentally on chest X-ray. Since its first description by Lutz in 1947, approximately 50 cases have been reported in the literature till date. The aim is to review the all reported intrathoracic ribs, summarize their clinical features, and propose a potential classification. Methods: All relevant literatures were searched and reviewed. The terms include intrathoracic rib, intrathoracic bifid rib, trans-thoracic rib and intrathoracic rib anomaly. We have summarized the first finding events, origination, distribution, related anomalies and imaging features of intrathoracic rib, and propose an updated classification. Results: The patients' age at initial finding was from six weeks to 79 years old. Of all, sixty percent was less than 30 years old. There was no difference in gender. Most of them were reported by authors in western countries (85.3%, 58/68), and incidental findings by radiologist and respiratory physician. The intrathoracic rib occurs more frequently on the right side, and is usually single and unilateral. According to the new classification, type I and II was account for 45.6% and 35.3%, respectively. Conclusion: Intrathoracic rib is rare findings in clinical practice. It is useful that radiologists or clinician are familiarized with the imaging appearances of these malformations. These anomalies reflect some disturbances during the embryo development, leading us to propose a potential classification that could contribute to a better understanding of this rib anomaly.

Enfermedad de Chester Erdheim costal: reporte de caso y revisión de la literatura / Chester Erdheim costal disease: case report and literature review

Introducción. La enfermedad de Erdheim Chester es un trastorno infrecuente, de etiología no clara y edad de presentación variable, que se caracteriza por la proliferación anormal de histiocitos no Langerhans. Puede presentarse de forma asintomática, con manifestaciones locales o como complicaciones sistémicas. El diagnóstico se basa en las condiciones clínicas del paciente, estudios imagenológicos y el estudio anatomopatológico, mediante el cual se confirma la enfermedad. Caso clínico. Paciente masculino con una lesión lítica en el séptimo arco costal, inicialmente asintomático y posteriormente con dolor torácico persistente. Se realizó resección y reconstrucción de la pared torácica, con resolución de la sintomatología y adecuada evolución posoperatoria. El resultado de la patología confirmó el diagnóstico de enfermedad de Erdheim Chester. Discusión. Se presenta el caso de un paciente con compromiso costal y fractura patológica como localización y manifestación inusual de la enfermedad de Erdheim Chester, tratado quirúrgicamente de forma adecuada, y sin aparición de recidiva. Debido a la diversidad de síntomas que pueden presentar y a la afectación de múltiples órganos, además de los estudios imagenológicos, la clínica debe orientar los exámenes complementarios, como electro o ecocardiograma, resonancia nuclear magnética, o angioTAC. En los pacientes asintomáticos se ha recomendado un manejo expectante y en los sintomáticos el tratamiento médico con glucocorticoides, inhibidores de BRAF e interferón alfa. El papel de la cirugía no ha sido estudiado a profundidad

Introduction. Erdheim Chester disease is a rare disorder of unclear etiology and variable age of presentation, characterized by abnormal proliferation of non-Langerhans histiocytes. It can present asymptomatic, with local manifestations or as systemic complications. The diagnosis is based on the clinical conditions of the patient, imaging studies, and the pathological study, through which the disease is confirmed.Clinical case. A male patient with a lytic lesion in the seventh costal arch, initially asymptomatic and later with persistent chest pain, underwent resection and reconstruction of the chest wall, with resolution of the symptoms and adequate postoperative evolution. The pathology report confirmed the diagnosis of Erdheim Chester's disease.Discussion. The case of a patient with rib involvement and pathological fracture is presented as an unusual location and manifestation of Erdheim Chester's disease, treated surgically appropriately, and without recurrence. Due to the diversity of symptoms that they can present and the involvement of multiple organs, in addition to imaging studies, the clinic should direct complementary tests such as electrocardiogram or echocardiogram, magnetic resonance imaging, or CT angiography. Expectant management has been recommended in asymptomatic patients, and medical treatment with glucocorticoids, BRAF inhibitors, and interferon alfa in symptomatic patients. The role of surgery has not been studied in depth

Traumatic thoracic rib cage and chest wall hernias: A review and discussion of management principles.

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches.

A Novel Classification of 3D Rib Cage Deformity in Subjects With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: This was a multicentric cross-sectional descriptive study. OBJECTIVE: To analyze patterns of 3D rib cage deformity in subjects with adolescent idiopathic scoliosis (AIS) and their relationship with the spinal deformity. SUMMARY OF BACKGROUND DATA: Subjects with AIS present with rib cage deformity that can affect respiratory functions. The 3D rib cage deformities in AIS and their relationship to the spinal deformity are still unelucidated. METHODS: A total of 200 AIS and 71 controls underwent low-dose biplanar x-rays and had their spine and rib cage reconstructed in 3-dimensional (D). Classic spinopelvic parameters were calculated in 3D and: rib cage gibbosity, thickness, width, volume and volumetric spinal penetration index (VSPI). Subjects with AIS were classified as: group I with mild rib cage deformity (n=88), group II with severe rib cage deformity (n=112) subgrouped into IIa (high gibbosity, n=48), IIb (high VSPI, n=48), and IIc (both high gibbosity and VSPI, n=16). RESULTS: Groups IIa and IIb had a higher Cobb angle (33 vs. 54 degrees and 46 degrees, respectively) and torsion index (11 vs. 14 degrees and 13 degrees, respectively) than group I. Group IIb showed more severe hypokyphosis (IIb=21 degrees; IIa=33 degrees; I=36 degrees; control=42 degrees) with a reduced rib cage volume (IIb=4731 cm3; IIa=4985 cm3; I=5257 cm3; control=5254 cm3) and thickness (IIb=135 mm; IIa=148 mm; I=144 mm; control=144 mm). Group IIa showed an increasingly large local gibbosity descending from proximal to distal levels and did not follow the axial rotation of the spine. Group IIc showed characteristics of both groups IIa and IIb. CONCLUSIONS: This new classification of 3D rib cage deformity in AIS shows that the management of cases with high VSPI (groups IIb and IIc) should focus on restoring as much kyphosis as possible to avoid respiratory repercussions. Treatment indications in groups I and IIa would follow the consensual basic principles reported in the literature regarding bracing and surgery.

Braces Designed Using CAD/CAM Combined or Not With Finite Element Modeling Lead to Effective Treatment and Quality of Life After 2 Years: A Randomized Controlled Trial.

STUDY DESIGN: Single-center prospective randomized controlled trial. OBJECTIVE: The aim of this study was to assess the computer-aided design/manufacturing (CAD/CAM) brace design approach, with and without added finite element modeling (FEM) simulations, after 2 years in terms of clinical outcomes, 3D correction, compliance, and quality of life (QoL). SUMMARY OF BACKGROUND DATA: .: Previous studies demonstrated that braces designed using a combination of CAD/CAM and FEM induced promising in-brace corrections, were lighter, thinner, and covered less trunk surface. Yet, their long-term impact on treatment quality has not been evaluated. METHODS: One-hundred twenty adolescent idiopathic scoliosis patients were recruited following Scoliosis Research Society standardized criteria for brace treatment; 61 patients in the first subgroup (CAD) were given braces designed using CAD/CAM; 59 in the second subgroup (CAD-FEM) received braces additionally simulated and refined using a patient-specific FEM built from 3D reconstructions of the spine, rib cage and pelvis. Main thoracic (MT) and thoraco-lumbar/lumbar (TL/L) Cobb angles, sagittal curves, and apical rotations were compared at the initial visit and after 2 years. Patient compliance and QoL were tracked respectively by using embedded temperature sensors and SRS-22r questionnaires. RESULTS: Forty-four patients with CAD-FEM braces and 50 with CAD braces completed the study. Average in-brace correction was 9° MT (8° CAD-FEM, 10° CAD, P = 0.054) and 12° TL/L (same for both subgroups, P = 0.91). Out-of-brace 2-year progression from initial deformity was <4° for all 3D measurements. Sixty-six percent of all cases (30 CAD-FEM, 35 CAD) met the ≤5° curve progression criterion, 83% (38 CAD-FEM, 43 CAD) stayed <45°, and 6% (5 CAD-FEM, 1 CAD) underwent fusion surgery. 3D correction, compliance, and QoL were not significantly different between both subgroups (P > 0.05). CONCLUSION: After 2 years, patients with braces designed using CAD/CAM with/without FEM had satisfying clinical outcomes (compared to the BrAIST study), 3D corrections, compliance and QoL. A more comprehensive optimization of brace treatment remains to be accomplished. LEVEL OF EVIDENCE: 2.

[Penrose Method Independent of the Rib Arch for Retraction of the Liver in Laparoscopic Gastrectomy y-Shape+1 Method].

We report the y-shape+1 method, which is a retraction of the liver method, independent of the position of the costal arch. Additionally, we report changes in liver enzymes induced by different methods of liver retraction. Three Penrose No. 6 drains were cut into 6 cm pieces. Penrose 1 was fixed with a thread attached to the end and Penrose 2 in a y-shape. A knitting thread with needles was prepared, and a loop was made at the end of the thread. The needle thread was passed over the abdominal wall and through the Penrose 2. The needle thread was passed over the diaphragmatic leg and through the Penrose 3. The thread was pulled over the abdominal wall and diaphragmatic leg and fixed to the end of Penrose 1 out of the body, and the liver was drained. The rate of change in liver enzymes from the preoperative to postoperative stages was examined separately in the Penrose and Nathanson groups. In the y-shape+1 technique, retraction of the liver can be performed regardless of the position of the rib arch; however, intracorporeal suture ligation is necessary. This method is useful when the conventional Penrose method is inappropriate because of the position of the rib arch.

Three-Dimensional Analysis of Preoperative and Postoperative Rib Cage Parameters by Simultaneous Biplanar Radiographic Scanning Technique in Adolescent Idiopathic Scoliosis: Minimum 2-Year Follow-Up.

STUDY DESIGN: Prospective study. OBJECTIVE: This study aimed to investigate the changes in rib cage deformity in adolescent idiopathic scoliosis (AIS) by comparing the preoperative and postoperative three-dimensional (3D) reconstruction images using simultaneous biplanar radiographic scanning technique (EOS) (EOS Imaging, Paris, France). SUMMARY OF BACKGROUND DATA: EOS data are limited for the analyses of preoperative and postoperative rib cage deformity. METHODS: A total of 67 Lenke type 1 or 2 AIS patients who underwent surgery (59 females and 8 males) were enrolled in this study. The mean patient age was 14.4 years (range: 11-17 yr). In all patients, posterior corrective fusion was performed with a rod rotation maneuver based on segmental pedicle fixation. Spinal parameters (scoliosis and kyphosis) and rib cage parameters (max thickness, thoracic index (TI), rib hump (RH), surface spinal penetration index (sSPI), end thoracic hump ratio, vertebra-sternum angle, rib vertebral angle difference at the apex, and vertebral lateral decentering), were measured. 3D images were assessed preoperatively and postoperatively at 2-year follow-up. RESULTS: Both main thoracic (MT) and proximal thoracic scoliosis were significantly corrected (51° to 15°, 30° to 17°, P < 0.0001). The rotation of MT apical vertebrae was also significantly corrected (12° to 5°, P < 0.0001). Thoracic kyphosis (T4-T12) significantly increased (13° to 18°, P < 0.0001). Besides, max thickness, TI, and RH demonstrated significant differences between preoperative and postoperative images (P < 0.01). T8-10 sSPI and end thoracic hump ratio decreased significantly postoperatively (P < 0.05). Although surgery significantly decreased vertebra-sternum angle (P < 0.0001), no significant difference was observed between the preoperative and postoperative rib vertebral angle difference (P = 0.32). Following the surgery, vertebral lateral decentering and rib cage volume were significantly increased (P < 0.0001). CONCLUSIONS: 3D reconstruction of the rib cage using biplanar standing stereoradiography is useful to evaluate preoperative and postoperative rib cage deformity in patients with AIS.Level of Evidence: 2.