Manubriectomy made easy.

Bone metastasis is the most common form of distant metastasis encountered within the breast cancer population. Surgical resection of bone metastases is a curative treatment option in patients who present with an isolated solitary lesion and no other associated disease. This decision is typically made following a multidisciplinary discussion. Patients can also be put forward for surgical excision of bone metastases following inadequate response to chemotherapy or radiotherapy.  With tumours located in the manubrium of the sternum, surgery serves not only to resect the bone metastasis but to provide suitable chest wall reconstruction. The goal of this approach is to maintain the structural and bony stability of the chest wall as well as that of associated structures, e.g. rib insertion or articulation of the shoulder girdle. A widely utilized approach involves excising the area of metastasis within the manubrium followed by implanting a bone cement prosthesis. Titanium plates are used to fix the bone prosthesis to the sternal body inferiorly and to the remainder of the manubrium superiorly.  We present a step-by-step video tutorial for performing a lower hemi-manubriectomy in a patient with triple-negative breast cancer. Our goal is to describe the fundamental principles and surgical techniques used to perform this procedure followed by the postoperative outcomes.

Anatomical study and meta-analysis of the episternal ossicles.

Episternal ossicles (EO) are accessory bones located superior and posterior to the manubrium, representing an anatomical variation in the thoracic region. This study aimed to investigate the prevalence and developmental aspects of EO in global populations. The prevalence of EO in pediatric populations was assessed using the "Pediatric-CT-SEG" open-access data set obtained from The Cancer Imaging Archive, revealing a single incidence of EO among 233 subjects, occurring in a 14-year-old patient. A meta-analysis was conducted using data from 16 studies (from 14 publications) through three electronic databases (Google Scholar, PubMed, and Journal Storage) encompassing 7997 subjects. An overall EO prevalence was 2.1% (95% CI 1.1-3.0%, I2 = 93.75%). Subgroup analyses by continent and diagnostic methods were carried out. Asia exhibited the highest prevalence of EO at 3.8% (95% CI 0.3-7.5%, I2 = 96.83%), and X-ray yielded the highest prevalence of 0.7% (95% CI 0.5-8.9%, I2 = 0.00%) compared with other modalities. The small-study effect was indicated by asymmetric funnel plots (Egger's z = 4.78, p < 0.01; Begg's z = 2.30, p = 0.02). Understanding the prevalence and developmental aspects of EO is crucial for clinical practitioners' awareness of this anatomical variation.

Right transmanubrial approach to the cervicothoracic spine with venous reconstruction.

The transmanubrial approach first reported by Grunenwald in 1997 is well-known for superior sulcus lung malignancies involving the thoracic inlet. Because an anterior approach to levels below Th2 is difficult without removing the manubrium, we used the transmanubrial approach for anterior cervicothoracic corpectomy and fusion (C7-Th3) in a patient with bilateral lower extremity paralysis due to ossification of the posterior longitudinal ligament in the cervicothoracic spine. To ensure more working space in the deep surgical field, which was hindered by a prior cardiac operation with median sternotomy and a goiter protruding into the upper mediastinal region, the right brachiocephalic vein was temporarily divided and subsequently reconstructed using bovine pericardium.

Stress fracture of the manubrium sterni during parallel bar dips.

OBJECTIVE: Stress fractures are common in highly active people, such as athletes or those in the military. They occur frequently in the lower extremities but sternal stress fractures are rare injuries. METHODS: We present a case of a young male who reported no pain and a 'click' sound from the front of the chest while training with parallel bar dips with a grip that was wider than shoulder-width apart. RESULTS: In this case, radiological evaluation was the most helpful tool to diagnose manubrium sterni stress fracture. We advised him to rest but he started exercises immediately because he had to participate in a military camp after the injury. The patient was treated conservatively. The treatment consisted of activity modification and supplemental drugs. CONCLUSION: We report a case of manubrium stress fracture that developed in a young male military recruit.

Delayed presentation of manubriosternal dislocation after thoracolumbar spondylodesis in a polytrauma patient - a case report.

BACKGROUND: Manubriosternal dislocations are a rare entity and frequently associated with thoracic spine fractures and, in minority of cases, with cervical or thoracolumbar fractures. METHODS: Our case represents a 38-year-old male who fell from a height resulting in multiple fractures, amongst others of the first lumbar vertebra. At primary survey and computed tomography scan no manubriosternal injury was apparent. After posterior stabilization of the thoracolumbar vertebrae a manubriosternal dislocation was identified and stabilized using plate-and-screw fixation. RESULTS: Clinical findings of a manubriosternal dislocation are not always obvious, allowing them to be missed at initial assessment. CONCLUSIONS: Manubriosternal dislocations can be missed at the initial investigation, even on cross-sectional imaging, and only become visible after spine stabilization because of the tight relationship between sternum and vertebrae in the thoracic cage. There is no unanimity in literature for surgical treatment of manubriosternal dislocations, although plate fixation is generally considered a safe and effective treatment option.

Surgical management of goiter with intrathoracic extension at the Philippine General Hospital Department of Otolaryngology Head and Neck Surgery

Objective@#To describe the demographic and clinical characteristics of patients diagnosed with intrathoracic thyroid masses managed surgically in our institution, determine associated factors affecting eventual operative approaches for these patients, and assess postoperative outcomes and complications associated with surgical intervention.@*Methods@#Design: Retrospective descriptive case series. Setting:Tertiary National University Hospital. Participants: 24 patients.@*Results@#The mean age of patients diagnosed with intrathoracic goiters was 55.71 years old, with a 1:1.4 male to female ratio; with most having an intrathoracic extent of Huins Grade 1 (67%) compared to others having Huins Grade 2-3. Majority of patients pre-operatively had a Fine Needle Aspiration (FNA) Bethesda Thyroid Nodule Classification of Category II (benign); 79% of total patients underwent excision of thyroid mass utilizing a transcervical approach alone. As Intrathoracic Extension (ITE) grade increased, additional transthoracic approaches were performed; duration of operation, average estimated blood loss, length of hospital stay was also noted to increase. Majority of post operative surgical histopathology results revealed malignant thyroid masses, in contrast to pre-operative FNA. Post-operative transient hypocalcemia was the most reported immediate complication. @*Conclusions@#Management of intrathoracic goiter is often multidisciplinary. Referral to the thoracic vascular service is warranted for access to the thoracic inlet. Classification by grade of intrathoracic goiters is helpful to determine the most appropriate operative approach and may be predictive of intraoperative and postoperative outcomes. Postoperative histopathology across all ITE grades mostly yield malignant results; hence, preoperative FNA results should be used with caution.

Heart transplantation using manubrium-sparing sternotomy for sternal re-entry.

We report a technique of heart transplantation performed by manubrium-sparing sternotomy for challenging re-entry after minimally invasive left ventricular assist device insertion. A T-shaped, manubrium-sparing sternotomy was performed using an oscillating saw up to the first intercostal space. After cardiopulmonary bypass was established via the right axillary artery and percutaneous venous cannulation of the right jugular and femoral vein, the outflow graft was ligated and divided via a left thoracotomy. All anastomoses were performed with a standard technique with an excellent exposure and outcome.

Anterior debridement, bone grafting and fixation for cervical spine tuberculosis: an iliac bone graft versus a structural manubrium graft.

BACKGROUND: Anterior debridement, decompression, bone grafting, and instrumentation are safe and effective techniques for patients with lower cervical spine tuberculosis. However, there is no consensus regarding the methods for using autogenous bone grafts. The purpose of this retrospective study was to compare the clinical outcomes of anterior surgical management for cervical spine tuberculosis by using an iliac bone graft versus a structural manubrium graft. METHODS: From January 2009 to September 2018, 23 patients with cervical spine tuberculosis were treated with anterior debridement, autogenous structural bone grafting and fixation at our spinal department. The patients were divided into 2 groups according to the different graft materials, namely, iliac crest bone grafts (Group A) and structural manubrium grafts (Group B). The clinical and radiographic results of the 2 groups were analyzed and compared. RESULTS: The mean duration of follow-up was 24 months. Bony fusion was achieved in all patients without failure of internal fixation. There were no significant differences between the two groups with respect to the operation time, blood loss, fusion time, neurological outcomes, or postoperative local Cobb angle (P > .05). However, the donor site complication rate in Group A was greater than that in Group B. The postoperative ambulation time in Group A was later than that in Group B. The mean visual analog scale (VAS) score for donor site pain in Group A was higher than that in Group B at 1 week after surgery (P < 0.05). However, there was no significant difference between the 2 groups at the last visit (P > .05). CONCLUSION: Both iliac bone grafts and sternal manubrium grafts can effectively reconstruct anterior column defects in anterior surgery. However, structural sternal manubrium autografts cause fewer complications associated with donor site morbidities than iliac bone grafts.

Manubrium Reconstruction.

To date, there is no standard approach for manubrial reconstruction. We had previously utilized mesh; however, this resulted in breakage, infection, and poor cosmesis. In this case series, we describe our transition to iliac wing autograft reconstruction. We examined 7 patients who underwent manubrial resection and reconstruction: 2 with mesh and methyl methacrylate and 5 with an iliac wing autograft. The outcomes of the autograft patients were overall favorable with no short-term complications or instances of breakage. We conclude that an iliac wing autograft for manubrial reconstruction is feasible and effective alternative to methyl methacrylate mesh.

Interclavicularis anticus digastricus muscle in a female body donor: a case report.

BACKGROUND AND OBJECTIVES: Muscular variations of the ventral thoracic wall are generally common and of great clinical interest. MATERIALS AND METHODS: An unusual muscular variation of the ventral thoracic wall was observed and dissected in a West-European female body donor. RESULTS: An interclavicularis anticus digastricus muscle was observed and studied. It originated from the manubrium sterni and inserted bilaterally to the clavicles. Both muscle bellies were interconnected by a tendon on the ventral surface of the manubrium sterni. The muscle was innervated by branches of the lateral pectoral nerve. CONCLUSIONS: The interclavicularis anticus digastricus muscle is a muscular variation of the ventral thoracic wall of unknown prevalence. This variation might be of clinical interest in orthopaedics and thoracic surgery. It is also a vulnerable structure during infraclavicular insertion of a subclavian vein catheter or fractures of the clavicle.

[Postoperative hearing in tympanoplasty preserving the manubrium of malleus and tensor tympani muscle tendon].

Objective:To study the effect of retaining the manubrium of malleus and tensor tympani muscle tendon （TT） on postoperative hearing reconstruction in tympanoplasty. Methods:Ninety-seven patients underwent tympanoplasty and ossiculoplasty in Peking University Third Hospital from January 2012 to December 2017, their postoperative results of audiometry were analyzed and compared with the preoperative results. The patients were divided into two groups according to retaining the manubrium of malleus and TT or not during the operation. Retention group include the cases with the manubrium of malleus and TT retained, resection group include the cases with TT resected with the manubrium retained or resected. T test was used to analyze and compare the differences of air conduction threshold air-bone gap （ABG） and the postoperative improvement between the two groups. Results:One year after operation, the air conduction thresholds and ABG were lower in retention group （n= 44） than those in resection group （n= 53） at each frequency, and there were differences with statistically significant at 0.25, 0.5 and 1.0 kHz （P<0.05）; the postoperative improvement of hearing thresholds and ABG at above frequencies in retention group was better than that in resection group. In cases with canal-wall-up operations or partial ossicular prostheses implanted, the above differences still existed between the two groups with statistical significance （P<0.05）; while in cases with canal-wall-down operations or total ossicular prostheses implanted, there were no significant differences between the two groups （P>0.05）. Conclusion:The preservation of the manubrium of malleus and TT is significant for postoperative hearing improvement in tympanoplasty, especially in the canal-wall-up operation with partial ossicular prostheses.

Retrosternal hematoma in sternal fracture for prediction of concomitant injury on chest CT.

BACKGROUND: Isolated sternal fracture, a benign injury, has been increasing in the pan-scan era, although one-third of patients with sternal fracture still has trouble with concomitant injury. The differentiation of these two entities is important to optimize patient management. PURPOSE: To evaluate correlation between retrosternal hematoma and concomitant injury in patients with sternal fracture and to identify predicting factors for concomitant injury in sternal fracture. MATERIAL AND METHODS: A total of 139 patients (84 men; mean age = 54.9 ± 15.3 years) with traumatic sternal fracture were enrolled in this study. We reviewed medical charts and multiplanar computed tomography (CT) images to evaluate cause, location, and degree of sternal fracture, retrosternal hematoma, and concomitant injury. Univariate and multivariate analysis were used to identify variables that were associated with concomitant injury. RESULTS: Concomitant injury on chest CT was observed in 85 patients with sternal fracture. Of the patients, 98 (70.5%) were accompanied by retrosternal hematoma. Multivariate analysis revealed that retrosternal hematoma (odds ratio [OR] = 5.350; P < 0.001), manubrium fracture (OR = 6.848; P = 0.015), and motor vehicle accident (OR = 0.342; P = 0.015) were significantly associated with sternal fracture with concomitant injury. CONCLUSION: Manubrium fracture and retrosternal hematoma portend a high risk of concomitant injury and indicate the need for further clinical and radiologic work-up.

Gorham-Stout disease of the mandible, manubrium and cervical spine presenting as bilateral chylothorax.

Gorham-Stout disease (GSD) is an extremely rare musculoskeletal disease of unknown aetiology characterised by non-neoplastic proliferation of vascular and lymphatic channels causing massive osteolysis, typically affecting younger individuals. Chylothorax is a known complication of GSD which is postulated to occur from thoracic spine involvement leading to pleural or thoracic duct invasion. In our case, bilateral chylothorax developed in a 60-year-old woman without any thoracic spine involvement of her disease, challenging the proposed mechanism. Despite bilateral pleural drainage and escalating doses of sirolimus, she ultimately developed respiratory failure and shock and succumbed to her illness. Overall survival of GSD is unknown, but when complicated by chylothorax, prognosis is typically poor. GSD represents a diagnostic and management challenge due to the paucity of knowledge surrounding its aetiology and management. These patients require multidisciplinary coordinated care. It is also important to note its high mortality when associated with chylothorax in particular.

CAD-based automatic modelling of customized cutting templates for Pectus Arcuatum surgical correction.

Pectus Arcuatum (PA) is a congenital chest wall deformity which produces a superior manubrial and sternal protrusion, particularly at the sternal angle. PA surgical correction to reduce the angle of the sternum always includes the removal of bone portion by means of horizontal sternal osteotomies, resection of deformed rib cartilage and finally stabilization of the anterior thoracic wall. Within this process an incorrect assessment of the sternotomy angle during the procedure may lead to the need for bone or cartilage grafts to fill the left voids. This problem has been addressed with a patient-specific cutting template, realized with Reverse Engineering and Additive Manufacturing techniques, which proved to be a key element to simplify the procedure and avoid the occurrence of this type of complications. In this work is presented and validated a procedure that, through common CAD operations, realizes in a completely automatic way the CAD model of the custom cutting template, so as to make non-expert users independent in the realization of the medical device.

Manubrial pseudolesion: a secondary sign of thoracic outlet syndrome.

Marrow enhancement mimicking sclerotic osseous disease, or the so-called transient "pseudolesion," has frequently been described in vertebral bodies supplied by collateral basivertebral venous flow in the setting of central venous obstruction. Pseudolesions involving the sternum are much rarer and have only been described in the setting of malignant central venous obstruction. We report a case of an incidental manubrial pseudolesion on contrast-enhanced CT prompting further investigation for thoracic outlet syndrome.