Management and Surgical Repair of Neonatal Sternal Cleft: A Case Report of Two Successful Interventions.

The sternal cleft (SC) is a rare congenital anomaly characterized by a complete or partial separation of the sternum, leading to significant clinical concerns, including respiratory and cardiac instability. Due to its rarity, the SC often poses surgical challenges. This case report highlights the management of two neonates with SCs, emphasizing the critical role of early multidisciplinary intervention. The first patient, a neonate, was born with a severe sternal deformity identified as a partial superior SC with a supraumbilical raphe. The patient was transported to a tertiary care center for further evaluation and management by a multidisciplinary team. Similarly, the second patient, another neonate, presented with similar sternal changes. Both patients were assessed for potential complications associated with sternal instability. The treatment involved surgical correction by closing the gap of the SC for both patients. The procedure included a midline skin incision, dissection and lateral reflection of the pectoralis major muscle, resection of cartilaginous plates for healthy cartilage fusion, and extension of the cleft through the manubrium to achieve anatomic closure by approximation and suturing. Intraoperative monitoring ensured the stability of cardiac and respiratory functions. Postoperative outcomes were favorable, with both patients recovering well and being discharged without complications on postoperative days 5 and 9. These cases highlight the significance of early surgical intervention with multidisciplinary management in neonates with SCs. The successful outcomes underscore the effectiveness of surgical intervention in preventing possible complications, ensuring rapid recovery, and stabilizing the chest. Further research into long-term outcomes and potential genetic factors may provide deeper insights into the management of this rare condition.

Development and evaluation of an automated breathing-synchronized chest wall vibration stimulation system.

[Purpose] Vibratory stimulation of the upper intercostal region enhances inspiratory movement, whereas stimulation of the lower intercostal region enhances expiratory movement and ventilation. Previous vibration stimulation devices for intercostal muscles required manual stimulation, causing a time lag between breathing and vibration stimulation. The purpose of this experiment was to compare the effects of an automatic vibration stimulation system with manual vibration stimulation in a group of individuals and to verify whether there was an increase in upper and lower chest wall displacement and respiratory flow. [Participants and Methods] Twenty healthy adults were divided into two groups, as follows: an automatic vibration stimulation group using a chest wall vibration stimulation system and a manual vibration stimulation group. Vibration stimulation was applied to the second intercostal space on both sides during inspiration, and to the seventh intercostal space on both sides during expiration. [Results] The vibration stimulation system group showed significantly higher synchronization rates during inspiration and expiration than the manual vibration stimulation group, and there was a significant increase in chest wall displacement and respiratory flow during inspiration and expiration. [Conclusion] The chest wall vibration stimulation system can effectively provide vibration stimulation to the intercostal muscles in synchrony with breathing.

Three-dimensional printed titanium chest wall reconstruction for tumor removal in the sternal region.

Resection of thoracic wall tumors results in significant defects in the chest wall, leading to various complications. In recent years, the use of three-dimensional (3D) printed titanium alloy prostheses in clinical practice has demonstrated enhanced outcomes in chest wall reconstruction surgery. A cohort of seven patients with sternal tumors was identified for this study. Following a helical CT scan, a digital model was generated for the design of the prosthesis. Subsequently, the tumors were then removed together with the affected sternum and ribs. The chest wall was then reconstructed using 3D-printed titanium alloy prosthesis for bone reconstruction, mesh for pleural reconstruction, and flap for soft tissue reconstruction. Patients were monitored for a period of one year post-surgery. In the seven cases examined, the tumors were found in various locations with varying degrees of invasion. Based on the scope of surgical resection and the size of the defect, 3D-printed titanium alloy prosthesis was custom-designed for chest wall reconstruction. Prior to bone reconstruction, pleural reconstruction was achieved with Bard Composix E/X Mesh, while soft tissue repair involved muscle flap and musculocutaneous flap procedures. A one-year follow-up assessment revealed that the utilization of the 3D-printed titanium alloy prosthesis led to secure fixation, favorable histocompatibility, and enhanced lung function. The findings demonstrate that the utilization of 3D printed titanium alloy prostheses represents a significant advancement in the field of chest wall reconstruction and thoracic surgical procedures.

Axillary Artery Injury Encountered During Chest Wall Tumor Resection.

Axillary artery injuries are rare because of their anatomy but are sometimes fatal because of the difficulty of obtaining vascular integrity. We report a 50-year-old patient with an iatrogenic axillary arterial injury that occurred during the resection of a chest wall tumor. The injury occurred during an incision of the intercostal muscle along the superior margin of the second rib. Following primary hemostasis achieved by forceps and amputation of the pectoralis minor muscle, the injury site was exposed sufficiently and successfully repaired by a vascular surgeon. This successful case provided valuable insight into strategies, primary hemostasis, and subsequent revascularization for an intraoperative vascular injury.

Neither Carinatum nor Excavatum: Insights Regarding the Novel Postprematurity Thoracic Dysplasia and Traditional Harrison Grooves.

BACKGROUND/PURPOSE: In recent years, a new chest wall malformation (CWM), the postprematurity thoracic dysplasia (PPTD), was reported. It was characterized as an inward deviation of the anterior tips of the 6th ribs and a personal history of prematurity and respiratory distress. At the moment, PPTD's prevalence and etiology are yet to be defined. Thus, we aimed to explore and identify patients with a compatible morphology within a large cohort of patients with CWM. METHODS: Retrospective analysis of electronic health records including medical photographs of 4640 consecutive patients with chest wall malformations at our Pectus Clinic between 2002 and 2023. Patients presenting with bilateral inward curvature of the 6th to 8th ribs were included. Among the variables analyzed, the history of preterm birth and ventilatory support requirement were evaluated. RESULTS: From 2069 patients with non-excavated deformities, 29 (1.4%) patients presented a PPTD morphology. After excluding 12 for incomplete records, we found that 9 patients (52.9%) had a positive history of prematurity (group PT) and 8 (47.1%) didn't (group T). However, both groups showed a high incidence of respiratory comorbidities (PT: 89% vs. T: 76%, p = 0.91). The median age of deformity onset was 12 months (IQR 2; 12) and 24 months (IQR 1; 60) for the PT and T groups, respectively (p = 0.37). Both groups showed a low incidence of family history of CWM (PT: 38% and T: 14%, p = 0.57). CONCLUSIONS: In this retrospective study including 4640 patients with chest wall malformations, the presence of a phenotype described as postprematurity thoracic dysplasia was similarly distributed among patients with or without a history of prematurity. We hypothesize that this condition, different from pectus excavatum and carinatum, might correspond to the Harrison grooves, a deformity whose etiology was profusely discussed in the medical literature from the first half of the 20th century. TYPE OF STUDY: Comparative retrospective study. LEVEL OF EVIDENCE: III.

Imaging of thoracic tuberculosis: pulmonary and extrapulmonary.

Tuberculosis (TB) remains the leading cause of death from a single infectious agent globally, despite being a potentially curable disease. This disease typically affects the lungs but may involve many extrapulmonary sites, especially in patients with risk factors such as HIV infection. The clinical features of extrapulmonary TB may mimic many different disease entities, particularly at less common thoracic sites such as the heart, chest wall, and breast. Imaging has an important role in the early diagnosis of TB, helping to detect disease, guide appropriate laboratory investigation, demonstrate complications, and monitor disease progress and response to treatment. Imaging supports the clinical objective of achieving effective treatment outcome and complication prevention. This review aims to highlight the imaging spectrum of TB affecting both pulmonary and extrapulmonary sites in the thorax. We also briefly provide key background information about TB, such as epidemiology, pathogenesis, and diagnosis.

Sternalis Muscle: A Cadaveric Case Report of a Rare Variant With Multiple Branching.

The sternalis muscle is a rare anatomical variant located in the anterior thoracic wall. Understanding variations in the sternalis muscle anatomy is essential for clinicians, especially radiologists and surgeons to prevent misdiagnosis and avoid complications during surgical procedures in the anterior thoracic region. We present a unique case of bilateral branched sternalis muscles. On either side, the sternalis muscle lies deep to the breast and superficial fascia and superficial to pectoralis major muscle and pectoral fascia. Each sternalis muscle is branched into medial and lateral slips with the medial slip larger than the lateral slip. The medial slip of the right sternalis was larger than the medial slip of the left sternalis. The lateral slip of the left sternalis was larger than the lateral slip of the right sternalis. The lateral slip of the left sternalis muscle has a curved course with superior-lateral convexity and inferomedial concavity. Near its middle, the left sternalis lateral slip is branched into two smaller slips separated by a narrow cleft. The left sternalis muscle in our report is a new variant with multiple branching, which cannot be matched to any type of the previously described classifications. In this case report, we discussed the need of modification of the currently available sternalis classification system to accommodate all types of the previously reported sternalis muscles including the branching pattern of this muscle.

Tuberculosis Causing a Pectoral Mass Mimicking Malignancy: A Rare Presentation of Tuberculosis.

Tuberculosis is an infectious disease that may involve all systems, with the respiratory system being the most commonly affected. Tuberculosis of the chest wall and its structures is rare, in which malignancy and abscess may be counted among possible differential diagnoses. In this case report, a patient with pectoral muscle tuberculosis will be presented. A 47-year-old female with a history of hypertension and epilepsy was evaluated for a rapidly enlarging painful mass under the left breast, which was later considered a cold abscess. The routine laboratory tests showed elevated C-reactive protein and erythrocyte sedimentation rate. Further radiological imaging with computed tomography confirmed the mass with chest wall involvement. The performed biopsy revealed granulomatous inflammation and subsequent tests confirmed acid-fast bacteria, with later confirmation of Mycobacterium tuberculosis in the culture. The patient was treated with an intensive regimen of anti-tuberculosis (TB) drugs consisting of isoniazid, rifampin, pyrazinamide, and ethambutol. After nine months, including a treatment extension due to possible vertebral involvement, the patient showed no symptoms and is under follow-up. Extrapulmonary TB, particularly musculoskeletal TB, comes with many diagnostic challenges due to its nonspecific symptoms. Tissue sampling remains the most important aspect of diagnosis confirmation and treatment planning; hence, TB should always be kept in mind among possible differential diagnoses, especially in endemic regions.

Ultrasound-Assisted Liposuction for Top Surgery in Transgender Men: Clinical Experience and Evaluation of Satisfaction and Quality of Life with TRANS-Q and BREAST-Q.

BACKGROUND: During the last decade, the demand for top surgery in female-to-male transgender (FMT) has increased worldwide. This study aims to present our initial experience with the novel use of ultrasound-assisted liposuction (UAL) in top surgery. Additionally, we evaluate the satisfaction and quality of life with TRANS-Q and BREAST-Q. METHODS: We conducted a retrospective study analyzing FMT undergoing UAL in top surgery from 2019 to 2021 at a single institution. We analyzed demographic variables, comorbidities, surgical techniques, operative time, complications, and follow-up time. We used TRANS-Q and BREAST-Q to evaluate patient-reported outcomes. A p value < 0.05 was considered significant. RESULTS: We performed 34 UAL combined subcutaneous mastectomies in 17 patients. Twelve patients (70.6%) underwent mastectomy double incision with free nipple grafting (DIFNG), and 29.4% underwent concentric circular mastectomy. In the DIFNG group, BMI (p < 0.02), the weight of each mammary gland (p < 0.001), and use of chest binder (p < 0.03) were significantly higher. The mean operative time was 115 min. The complication rate was 11.7% (one hematoma and three hypertrophic scars). The mean follow-up was 29.4 months, and no aesthetic revision surgeries was reported. The response rate for TRANS-Q and BREAST-Q was 76.5%, and high satisfaction with the results and significant improvement in quality of life were reported. CONCLUSIONS: We present the first cohort of transgender men who underwent UAL in top surgery. With proper training, the use of UAL could be a feasible and safe technique, offering good long-term esthetic results. Additionally, TRANS-Q and BREAST-Q demonstrated improved satisfaction and quality of life. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Chest wall subcutaneous mass leading to the diagnosis of pericostal tuberculosis.

When diagnosing a chest wall mass, even in the absence of pulmonary lesions, it is crucial to consider pericostal tuberculosis as a differential diagnosis. Attention must be paid to the characteristic findings on contrast-enhanced computed tomography, such as central low attenuation, peripheral rim enhancement of soft tissue, and pleural involvement.

Tubercular Costochondritis Presenting as Chest Wall Swelling: A Case Report of an Atypical Tuberculosis Presentation.

Costochondritis is an inflammatory condition of the costochondral junctions, rarely due to tuberculosis (TB). One-quarter of the world's population is affected by tuberculosis, while musculoskeletal tuberculosis accounts for only 1-2% of the total cases. Among these cases, the involvement of the ribs is extremely rare. The following case report describes a 60-year-old male with diabetes who had recurrent thoracic wall swelling with greenish discharge for 23 years, misdiagnosed and treated as sebaceous cysts. Recently, at its exacerbation, imaging and biopsy revealed tubercular costochondritis, a very rare form of extrapulmonary tuberculosis that affects the ribs. Antituberculous therapy administered for nine months showed complete resolution of symptoms. This case underscores the key issue of placing tuberculosis within the differential diagnosis for a chest wall swelling, highlighting its diagnostic challenge in this atypical presentation. Advanced imaging and histological examination were of importance in coming up with an accurate diagnosis; hence, clinical suspicion needs to be increased and more research done in the light of management guidelines for this rare condition.

Spontaneous Chest Wall Hernias: Intercostal Lung Hernia and Inverted Intercostal Hernia.

Intercostal lung hernia and inverted intercostal hernia are rare chest wall hernias usually asymptomatic and detected incidentally on chest radiograph. In this case report, we discussed here on the chest radiograph and computed tomography imaging findings of two cases of these rare hernias with an emphasis being in differential diagnosis of chest tumors.

Benefits of chest wall mobilization on respiratory efficiency and functional exercise capacity in people with severe chronic obstructive pulmonary disease (COPD): A randomized controlled trial.

BACKGROUND: Coexistence of chest wall hypomobility and lung hyperinflation compromises respiratory muscle function and respiratory efficiency in people with severe chronic obstructive pulmonary disease (COPD). This study aimed to investigate the effect of chest wall mobilization on functional exercise capacity, respiratory muscle activity and respiratory muscle tissue oxygen saturation for people with severe COPD. METHODS: Thirty male adults (age: 75 ± 6) diagnosed with severe COPD completed a 6-week programme (twice/week) according to intervention randomization (chest wall mobilization group, CWMG, n = 15; control group, CG, n = 15). Both groups received standardized education and walking exercise, while CWMG also received chest wall and thoracic spine mobilization. Electromyography of the essential and accessory respiratory muscles and tissue oxygen saturation of the intercostal muscle (StO2, measured by near-infrared spectroscopy) during incremental cycle exercise test were measured and compared between the two groups at pre-programme, post-programme and 3-month follow-up. RESULTS: Patients in CWMG demonstrated a significant increase in exercise tolerance from <3 METS to 4-6 METS (p = 0.000) after intervention. A significant decrease in activity of scalene, sternocleidomastoids and intercostal muscle during exercise test (p < 0.01) was found in CWMG, as compared to CG. A significant decrease in StO2 (p < 0.05) and greater decline in the slope of oxygenation dissociation (p = 0.000) were seen in CWMG during exercise test. These positive results were maintained at 3-month follow-up in CWMG. CONCLUSION: Improvements in exercise tolerance, respiratory muscle efficiency and oxygenation extraction ability in CWMG suggest a potential clinical benefit of integrating chest wall and thoracic spine mobilization for rehabilitation of people with severe COPD.

Chest wall muscle area, ventilatory efficiency and exercise capacity in systemic sclerosis.

To investigate the potential contribution of chest wall muscle area (CWMA) to the ventilatory efficiency and exercise capacity in patients with Systemic Sclerosis (SSc) without interstitial lung disease (ILD). Forty-four consecutive SSc patients [F = 37, median age 53.5 years (IQR 43.5-58)] were examined using chest high-resolution computed tomography (HRCT), pulmonary function tests and cardiopulmonary exercise testing (CPET). The CWMA was evaluated at the level of the ninth thoracic vertebra on CT images by two independent evaluators blinded to the patient information. CPET parameters analyzed were maximum oxygen uptake (VO2 max) and VO2 at anaerobic threshold (VO2@AT); minute ventilation (VE); maximum tidal volume (VT). A statistically significant positive correlation was found between CWMA and maximum workload (r = 0.470, p < 0.01), VO2 max ml/min (r = 0.380, p < 0.01), VO2@AT (r = 0.343, p < 0.05), VE (r = 0.308, p < 0.05), VT (r = 0.410, p < 0.01) and VO2/heart rate (r = 0.399, p < 0.01). In multiple regression analysis, VO2 max (ml/min) was significantly associated with CWMA [ß coefficient = 5.226 (95% CI 2.824, 7.628); p < 0.001], diffusing capacity for carbon monoxide (DLco) [ß coefficient = 6.749 (95% CI 1.460, 12.039); p < 0.05] and body mass index (BMI) [ß coefficient = 41.481 (95% CI 8.802, 74.161); p < 0.05]. In multiple regression analysis, maximum workload was significantly associated with CWMA [ß coefficient = 0.490 (95% CI 0.289, 0.691); p < 0.001], DLco [ß coefficient = 0.645 (95% CI 0.202, 1.088); p < 0.01] and BMI [ß coefficient = 3.747 (95% CI 1.013, 6.842); p < 0.01]. In SSc-patients without ILD, CWMA represents an important variable in exercise capacity and can be evaluated by the mediastinal window available in the HRCT images required for lung disease staging.

Chest Wall Reconstruction Using Titanium Mesh in a Dog with Huge Thoracic Extraskeletal Osteosarcoma.

A 6-year-old castrated male mixed dog presented with a rapidly growing mass at the right chest wall two weeks after initial detection. A mesenchymal origin of the malignancy was suspected based on fine-needle aspiration. Computed tomography (CT) revealed that the mass originated from the right chest wall and protruded externally (6.74 × 5.51 × 4.13 cm3) and internally (1.82 × 1.69 × 1.50 cm3). The patient revisited the hospital because of breathing difficulties. Radiography confirmed pleural effusion, and ultrasonography-guided thoracocentesis was performed. The effusion was hemorrhagic, and microscopic evaluation showed no malignant cells. Before surgery, CT without anesthesia was performed to evaluate the status of the patient. The 7-10th ribs were en bloc resected at a 3-cm margin dorsally and ventrally, and two ribs cranially and caudally from the mass. After recovering the collapsed right middle lobe of the lung due to compression from the internal mass with positive-pressure ventilation, a 3D-printed bone model contoured titanium mesh was tied to each covering rib and surrounding muscles using 2-0 blue nylon and closed routinely. The thoracic cavity was successfully reconstructed, and no flail chest was observed. The patient was histo-pathologically diagnosed with extraskeletal osteosarcoma. A CT scan performed 8 months after surgery showed no evident recurrence, metastasis, or implant failure. This is the first case report of chest wall reconstruction using titanium mesh in a dog. The use of a titanium mesh allows for the reconstruction of extensive chest wall defects, regardless of location, without major postoperative complications.

Chest wall resection and reconstruction for primary chest wall sarcomas: analysis of survival, predictors of outcome and long-term functional status.

OBJECTIVES: We aimed to analyze survival, predictors of outcome and the long-term functional status of patients with a diagnosis of primary chest wall sarcoma who undergo chest wall resection and reconstruction (CWRR). METHODS: We analysed a prospectively maintained database, including all patients operated on between 2008-2021. The primary outcome measures were overall and disease-free survival and analyses were employed to determine the risk factors for poor survival and recurrence. RESULTS: One hundred and thirty-nine patients included, 55% were male. The majority (96%) had an R0 resection and 75.1% had no post-operative complications up to 30 days post procedure; median length of hospital stay was 7 (6-10) days. Median overall and disease-free survival (DFS) was 58.8 and 53.6 months respectively. For those alive, at long-term follow-up, 80% had a Medical Research Council (MRC) dyspnoea score of 0 and Karnofsky index >80%. Survival and mortality rates were better in chondrosarcomas compared to non-chondromatous sarcomas (p<0.05). Previous history of radiotherapy, previous history of cancer, the type of sarcoma (Ewing's or soft tissue), the need for adjuvant treatment and tumour grade were significant predictors of mortality and recurrence on univariate testing. Extended resection, a higher number of ribs removed, and the incidence of post-operative complications were significantly associated with a worse post-operative MRC score. CONCLUSIONS: Careful patient selection and multi-disciplinary decision-making is crucial. This leads to clear resection margins, good overall and disease-free survival and good functional outcomes.

Beware of the Iceberg Phenomenon: A Case Report of Chest Wall Fibrous Dysplasia.

Thoracic fibrous dysplasia (FD) is a benign, osseous chest wall tumor. It originates from bone marrow and accounts for 30-50% of all benign osseous neoplasms in the chest wall. In FD, normal bone marrow is replaced by fibrous stroma and immature bone. We present a rare case in which massive intrathoracic polyostotic FD originating from the rib was diagnosed and treated. The extrathoracic part of the tumor appeared stable and unalarming for decades; however, in hindsight, the intrathoracic part significantly progressed, eventually leading to symptoms. The tumor was removed through a hemi-clamshell approach, which allowed adequate visualization and control of mediastinal structures. After establishing the diagnosis of FD, regular follow-up imaging is crucial for timing of a surgical intervention to prevent symptoms, impairment of quality of life, and unnecessarily complex resections.

Does PIC score pick correctly? Evaluation of a modified-PIC based admission a single institution retrospective cohort study.

INTRODUCTION: The Pain, Inspiratory effort, Cough score (PIC) has been developed and widely adopted to guide clinical prognostication for patients with chest wall injury. To date, the efficacy, accuracy, and safety of a PIC based triage system has not been validated. Therefore, this study sought to evaluate the use of a modified-PIC score to triage and down-grade trauma patients with chest wall injury at a single institution. METHODS: A retrospective study was conducted at a large, Level I Trauma Center on patients with chest wall injuries admitted between 1/1/2018-10/31/20,222. On 12/1/2020, our institution implemented a modified-PIC triage tool including the PIC score, age, and severity of chest wall injury. The Pre-PIC (1/1/2018-11/20/2020) and Post-PIC (1/1/2021-10/31/2022) groups were composed based on admission date and outcomes between the two were compared. RESULTS: 2,627 patients comprised the Pre-PIC group and 2,212 patients comprised Post-PIC. The groups didn't differ significantly in demographics or mechanisms of injury except for COVID status. Post-intervention, a greater proportion of patients were triaged to the intermediate care unit instead of the ICU or floor. There were no significant differences in hospital length of stay (LOS), ventilator days, unplanned ICU admission, or mortality in Pre-PIC vs Post-PIC. ICU LOS, rates of ARDS, and cardiac arrest with return of spontaneous circulation (ROSC) were significantly lower in Post-PIC. Multivariable models demonstrated significantly lower ARDS rates and ICU free days. ICU LOS trended towards significance as well. CONCLUSIONS: This is the largest study, to date, evaluating the impact of a modified-PIC triage system on clinical outcomes. The results suggest a modified-PIC triage system may lead to decreased ICU days, ARDS rates, and rates of cardiac arrest w/ ROSC, potentially improving hospital resource allocation. Further prospective and multi-center studies are needed to validate our understanding on the impact of a chest wall scoring system on triage and outcomes.