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.

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.

In vitro comparison of personalized 3D printed versus standard expandable titanium vertebral body replacement implants in the mid-thoracic spine using entire rib cage specimens.

BACKGROUND: Expandable titanium implants have proven their suitability as vertebral body replacement device in several clinical and biomechanical studies. Potential stabilizing features of personalized 3D printed titanium devices, however, have never been explored. This in vitro study aimed to prove their equivalence regarding primary stability and three-dimensional motion behavior in the mid-thoracic spine including the entire rib cage. METHODS: Six fresh frozen human thoracic spine specimens with intact rib cages were loaded with pure moments of 5 Nm while performing optical motion tracking of all vertebrae. Following testing in intact condition (1), the specimens were tested after inserting personalized 3D printed titanium vertebral body replacement implants (2) and the two standard expandable titanium implants Obelisc™ (3) and Synex™ (4), each at T6 level combined with posterior pedicle screw-rod fixation from T4 to T8. FINDINGS: No significant differences (P < .05) in primary and secondary T1-T12 ranges of motion were found between the three implant types. Compared to the intact condition, slight decreases of the range of motion were found, which were significant for Synex™ in primary flexion/extension (-17%), specifically at T3-T4 level (-46%), primary lateral bending (-18%), and secondary lateral bending during primary axial rotation (-53%). Range of motion solely increased at T8-T9 level, while being significant only for Obelisc™ (+35%). INTERPRETATION: Personalized 3D printed vertebral body replacement implants provide a promising alternative to standard expandable devices regarding primary stability and three-dimensional motion behavior in the mid-thoracic spine due to the stabilizing effect of the rib cage.

Capacidade pulmonar e funcional no pós-operatório de mulheres submetidas à mastectomia: série de casos / Pulmonary and functional capacity in the post-surgery of women submitted to mastectomy: preliminary results

Mulheres submetidas à cirurgia de mastectomia podem apresentar algumas complicações, dentre elas, alterações respiratórias e prejuízo funcional. O objetivo deste estudo foi avaliar a cinemática da parede torácica e a capacidade funcional no pós-operatório de pacientes mastectomizadas sem tratamento neoadjuvante e adjuvante associados. Foram avaliadas 4 mulheres no grupo mastectomia (GM) e 4 mulheres no grupo controle (GC). Todas as participantes foram submetidas aos procedimentos de avaliação antropométrica, função pulmonar, força muscular respiratória, cinemática da parede torácica e capacidade funcional. O GM também foi submetido à avaliação de inspeção e palpação torácica. Os dados foram analisados por meio de estatística descritiva. Foi observado que o GM apresentou menor variação de volume corrente da parede torácica, com delta de variação de 22,03% a menos que o GC, sendo a maior redução de volume corrente evidenciada no compartimento de caixa torácica pulmonar, com redução de 41,57% em relação ao GC. O GM não apresentou alterações de função pulmonar, força muscular respiratória e capacidade funcional, apresentando valores de normalidade nessas avaliações. Portanto, mulheres submetidas ao procedimento cirúrgico de mastectomia, sem tratamento neoadjuvante e adjuvante associados, não apresentaram comprometimento da função pulmonar, da força muscular respiratória e da capacidade funcional, contudo foi verificado redução do volume pulmonar na região do procedimento cirúrgico.

Women submitted to a mastectomy surgery may present some complications, among them, respiratory changes and functional impairment. The purpose of this study was to evaluate the chest wall kinematics and functional capacity in the postoperative period of mastectomized patients without associated adjuvant and neoadjuvant treatment. A total of four (4) women in the mastectomy group (MG) and four (4) in the control group (CG) were evaluated. All participants were submitted to the procedures of anthropometric evaluation, pulmonary function, respiratory muscle strength, chest wall kinematics and functional capacity. Patients in MG were also submitted to an inspection and palpation evaluation of the chest and breasts. Database was analyzed using descriptive statistics. It was observed that the MG presented a smaller variation of tidal volume of the chest wall, with a variation delta of 22.03% less than CG, with the largest reduction in tidal volume evidenced in the pulmonary chest cavity compartment, with a reduction of 41.57% when compared to CG. The MG did not present alterations of pulmonary function, respiratory muscle strength and functional capacity, presenting values of normality in these evaluations. Therefore, women submitted to the surgical procedure of mastectomy without associated neoadjuvant and adjuvant treatment did not present any impairment of pulmonary function, respiratory muscle strength and functional capacity. However, a reduction could be observed in the pulmonary volume in the region of the surgical procedure.

Rib Cage Stabilisation With 3D-Printed Polyethylene Sternal Prosthesis Post-Sternotomy Mediastinitis.

BACKGROUND: Post-sternotomy mediastinitis (PSM) is a serious complication of median sternotomy. It is associated with a high mortality rate. Evidence based management recommends debridement followed by closure with vascularised flaps. When large areas of resections are performed, the use of sternal prosthesis could be considered to ensure chest wall stability and cosmesis. METHOD: We report an individualised three-dimensional (3D)-printed high-density polyethylene (HDPE) sternum implantation in a patient with a 10 cm chest wall defect. RESULTS: Chest wall reconstruction was uncomplicated and the patient tolerated the procedure well without cardiorespiratory compromise. Postoperatively, the wound healed well and the chest wall remained stable at outpatient clinic follow-up. CONCLUSION: Three-dimensional-printed HDPE prosthesis offers an alternative implant option for closing large chest wall defects for eroded sternum after cure of mediastinitis.

Quadrangular Fixation of Pectus Bars to Prevent Displacement in Nuss Procedure.

BACKGROUND: Double pectus bars are sometimes inserted to correct pectus excavatum. Method of double-bar fixation to prevent bar displacement has been rarely reported. We have used quadrangular fixation of the double pectus bars. The objective of this study was to compare results of the quadrangular fixation procedure with those of the classic separate fixation procedure. METHODS: From September 2011 to January 2016, 86 patients underwent Nuss procedure with double-bar insertion. In 44 patients, each bar was fixed separately (group A). In 42 patients, quadrangular fixation of the bars was performed with metal plates (group B). Patient demographics, Haller index (HI), bar displacement index (BDI), and reoperation rate were compared between the two groups. RESULTS: The mean patient age was 17.2 years (range: 3-40 years) in group A and 17.8 years (range: 4-30 years) in group B. There was no significant difference in preoperative or postoperative HIs between the two groups (all p >0.05). Early complication rates were 15.9% in group A and 9.5% in group B (p > 0.05). In group A, three patients underwent surgery to correct bar displacement (6.8% of reoperation rate), whereas there was no corrective surgery in group B. BDIs of the two groups were significantly different (p < 0.01). CONCLUSIONS: When quadrangular fixation was performed with upper and lower pectus bars bilaterally fixed by connecting each bar with plates, bar displacement was prevented more effectively than separate fixation, thus minimizing reoperation.

Improved Dynamics of Thoracic Cage and Exercise Capacity after Nuss Repair for Pectus Excavatum.

BACKGROUND: Pectus excavatum (PE) reduces the dynamics of the thoracic cage, with a negative impact on exercise capacity. We aimed to evaluate the effects of Nuss repair for PE on the dynamics of the thoracic cage and exercise capacity in adults. METHODS: This was a prospective observational study of 46 adults (mean age, 26.2 years) who underwent PE correction using the Nuss procedure between September 2016 and August 2017. Cirtometry was used to obtain measures of thoracic cage circumference at two levels (axillary level [AL] and xyphoid level [XL]), at the end points of inspiration and expiration. Circumference measures were obtained before surgery and at 1, 3, and 6 months after surgery. Exercise capacity was also evaluated using the 6-minute walk test (6MWT). The association between the 6MWT data and cirtometry measures was evaluated using Pearson's correlation. RESULTS: The circumference at maximum inspiration increased from baseline to 3 months after surgery (p < 0.01), at both the AL (84.5 ± 4.9 vs. 88.5 ± 5.1 cm) and XL (80.1 ± 4.8 vs. 83.7 ± 5.1 cm). The 6MWT also significantly improved from baseline to 3 months after surgical correction (544.7 ± 64.1 vs. 637.3 ± 59.4 m, p < 0.01), with this improvement being correlated to the increase in thoracic circumference on maximal inspiration at both the AL and XL (0.8424 and 0.7951, respectively). CONCLUSION: Improved dynamics of the thoracic cage were achieved after Nuss repair for PE in adults. This increase in thoracic circumference at maximum inspiration was associated with an improvement in exercise capacity at 3 months after surgery.

Risk factors of cage subsidence after removal of localized heterotopic ossification by anterior cervical discectomy and fusion: A retrospective multivariable analysis.

The purpose of the study was to identify risk factors of cage subsidence and evaluate surgical outcome by at least 12 months postoperative follow-up.We retrospectively investigated 113 consecutive patients who underwent anterior surgery to relieve spine cord compression resulted from localized heterotopic ossification, from July, 2011 to February, 2016. We divided the patients into 2 groups: cage subsidence <2 mm group and ≥2 mm group. According to magnetic resonance imaging (MRI), the severity of increased signal intensity (ISI) was classified into grade 0, 1, and 2. Clinical outcome was assessed by the Japanese Orthopedic Association (JOA) scoring system. Logistic regression analysis and receiver-operating characteristic (ROC) curve were utilized for predicting risk factors of cage subsidence, and the recovery rate was evaluated by Kruskal-Wallis test or Mann-Whitney U test.Logistic regression with cage subsidence as the dependent variable showed independent risks associated with a cervical sagittal malalignment (odds ratio [OR] 11.23, 95% confidence interval [CI] 3.595-35.064, P < .001), thoracic 1 (T1) slope angle (OR 1.59, 95% CI 1.259-1.945, P < .001), and excisional thickness (OR 2.38, 95% CI 1.163-4.888.0, P = .018). The cut-off values of T1 slope and excisional thickness were 19.65 angle and 3.7 mm, respectively. Patients with high occupying ratio (P = .001) and high ISI grade (P = .012) are more likely to occur lower recovery rate.Patients with high T1 slope angle or preoperative kyphotic deformity should avoid excessive removal of endplate and vertebral body so as to reduce the occurrence of cage subsidence. Poor outcome was closely related to cervical sagittal malalignment and higher ISI grade.

Winged Ribs: An Underestimated Problem That May Compromise Breast Augmentation Outcomes.

Chest wall shape is an important aspect to consider when planning a breast augmentation. Minor chest wall deformities are usually underestimated by the patient and surgeon and may compromise postoperative outcomes. Lower costal cartilage dysmorphia or winged rib is one of these minor underestimated chest wall deformities characterized by a visible and palpable cartilaginous prominence under the inframammary fold and causes discomfort in patients decreasing the satisfaction with the breast augmentation surgery. For these patients, the author utilized an innovative surgical technique that allows resection of the protruding cartilages and placement of breast implants through the same surgical incision. Six patients with winged ribs underwent breast augmentation and costal cartilage resection via this method and there were no intraoperative or early postoperative complications, and all patients were satisfied with the aesthetical result after 6 months of follow-up. The presented surgical technique has a short learning curve with excellent postoperative results. Cases are presented to demonstrate the improved postoperative chest wall contour combined with breast augmentation outcome.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 .

Unifying classification for transdiaphragmatic intercostal hernia and other costal margin injuries.

OBJECTIVES: Taxonomy of injuries involving the costal margin is poorly described and surgical management varies. These injuries, though commonly caused by trauma, may also occur spontaneously, in association with coughing or sneezing, and can be severe. Our goal was to describe our experience using sequential segmental analysis of computed tomographic (CT) scans to perform accurate assessment of injuries around the costal margin. We propose a unifying classification for transdiaphragmatic intercostal hernia and other injuries involving the costal margin. We identify the essential components and favoured techniques of surgical repair. METHODS: Patients presenting with injuries to the diaphragm or to the costal margin or with chest wall herniation were included in the study. We performed sequential segmental analysis of CT scans, assessing individual injury patterns to the costal margin, diaphragm and intercostal muscles, to create 7 distinct logical categories of injuries. Management was tailored to each category, adapted to the individual case when required. Patients with simple traumatic diaphragmatic rupture were considered separately, to allow an estimation of the relative incidence of injuries to the costal margin compared to those of the diaphragm alone. RESULTS: We identified 38 patients. Of these, 19 had injuries involving the costal margin and/or intercostal muscles (group 1). Sixteen patients in group 1 underwent surgery, 2 of whom had undergone prior surgery, with 4 requiring a novel double-layer mesh technique. Nineteen patients (group 2) with diaphragmatic rupture alone had a standard repair. CONCLUSIONS: Sequential analysis of CT scans of the costal margin, diaphragm and intercostal muscles defines accurately the categories of injury. We propose a 'Sheffield classification' in order to guide the clinical team to the most appropriate surgical repair. A variety of surgical techniques may be required, including a single- or double-layer mesh reinforcement and plate and screw fixation.

Nontraumatic rupture of the costal margin: a single-center experience.

BACKGROUND: Rupture of the costal margin is uncommon. Whilst most often seen after major trauma, we describe its occurrence in patients with no direct chest trauma. METHODS: A search was performed in our thoracic surgery database for all patients with rupture of the costal margin. Patients were excluded if the injury was a result of trauma. Data were collected on sex, age, body mass index, profession, past medical history, smoking status, presenting complaint, mechanism of injury, and management. RESULTS: There were 9 patients with rupture of the costal margin that was caused in all cases by a severe coughing fit. All patients were male and the mean age was 62.5 years (range 47-76 years). Chronic obstructive pulmonary disease was present in 6 cases. Presentations included a palpable defect (5 cases), cough (9 cases), and chest pain (6 cases). On radiological examination, all patients had widening of the rib space, 4 had associated rib fractures, and 5 had lung herniation. Time from injury to presentation was 12 months (range 1-24 months). All patients underwent surgery and were followed-up for 59 months (range 8-129 months). Two patients suffered major complications in the immediate postoperative period. CONCLUSIONS: Rupture of the costal margin, in the absence of direct trauma, is characterized by pain, a palpable defect, and lung herniation. It is associated with widening of the rib space and rib fractures, and can be treated surgically with success but not without significant risks.

Internal driveline damage under the costal margin several years after HeartMate II implant: a series of three cases.

Although the incidence of driveline failure has been significantly reduced with the major modification to the driveline connection to the HeartMate II left ventricular assist device (LVAD), internal and external driveline damage continues to be a major reason for pump exchange or driveline repair. We report three cases of internal driveline damage under the costal margin and in the adjacent abdominal wall. All three cases developed occasional electrical disruptions 2-5 years after the original LVAD implant through the median sternotomy. Two patients underwent subcostal LVAD exchange and one had driveline externalization and repair. The driveline velour was well adhered to the costal margin and wire damage was found at the costal margin as well as the subsequent segment in the abdominal wall. Repeated ante-flex bending of the abdominal wall over years appeared to cause the chronic wear and tear of the vertically located driveline under the costal margin. This report will confirm a pitfall of the LVAD driveline location which can potentially cause driveline damage in the mid-to-long term.

[Giant Cell Tumor of the Rib;Report of a Case].

We report a rare case of giant cell tumor of the rib. A 33-year-old man was admitted to our hospital because of a recently appearing mass and pain in the right chest wall. Chest computed tomography and magnetic resonance imaging revealed a heterogeneous mass of 8-cm in diameter arising from and destroying the right 7th rib. The tumor was resected together with the 6th, 7th, and 8th ribs and the adjacent muscle and diaphragm. The pathological diagnosis was giant cell tumor of the bone. The patient has been free from recurrence or metastasis for 4 years after the operation.

An In Vitro Biomechanical Study on Ovine Rib Flexibility With Increasing Deconstruction-As an Alternative to Rib Resection for Costoplasty.

STUDY DESIGN: An in vitro biomechanical study into the effect of rib deconstruction on the flexibility in ovine ribs, using three-point bending. OBJECTIVE: To examine the feasibility and possible effectiveness of a more conservative costoplasty using an in vitro animal model. SUMMARY OF BACKGROUND DATA: Costoplasty remains useful in the treatment of adolescent idiopathic scoliosis, rib hump, and associated chest wall deformities. However, traditional costoplasty increases morbidity and blood loss. METHODS: Ribs 2-10 were dissected from four fresh half ovine rib cages. The ribs were randomly allocated to Groups 1 to 4. The ribs underwent deconstruction, 10 mm from the lateral tubercle and 30 mm long, according to their group: Group 1 = control; Group 2 = convex cortical bone removed; Group 3 = convex cortical and cancellous bone removed; Group 4 = all but the ventral cortex is removed. Flexibility was tested by loading the concave side of each rib while fixed at the rib head and equidistant from the center of the resected area. The ribs were deformed at 0.5 mm/s up to a maximum load of 9.99 kg or fracturing. Load was plotted against displacement to find the load/displacement coefficient for each group. Statistical analysis was by an analysis of variance with Tukey's honestly significant difference post hoc testing. RESULTS: The load/displacement coefficients were as follows: Group 1 = 131.93 (±27.52) N/mm, Group 2 = 93.36 (±40.71) N/mm, Group 3 = 88.66 (±25.84) N/mm, and Group 4 = 29.69 (±29.11) N/mm. Group 4 was significantly less stiff than Groups 1, 2, and 3 (p < .01). No ribs in Groups 1, 2, and 4 fractured. Five of 8 ribs in Group 3 fractured during loading. CONCLUSIONS: Deconstructing the rib down to the concave side significantly increases the flexibility by approximately 4.5 times. Despite large removal of bone, it retains the ability to withstand 10 kg of load without fracture.

Traumatic thoracic rib cage hernias: Operative management and proposal for a new anatomic-based grading system.

BACKGROUND: Traumatic Rib Cage Hernias (TRCH) requiring operative repair are rare and there is currently no literature to guiding surgical management. METHODS: Perioperative review of TRCH over 32 years. Five operative grades were developed based on extent of tissue/bone damage, size, and location. RESULTS: Twenty-four patients (20 blunt, 4 penetrating) underwent operative repair. Lung was the herniated organ in 88% with a median of 4 rib fractures and average size of 60.25 cm. Types of operation were well clustered by assigned TRCH grade. The majority required mesh (75%) and/or rib plating (79%). Complex tissue flap reconstruction was required in 10%. Full range-of-motion was maintained in 88% with79% returning to pre-injury activity levels. Five patients had continued pain at final follow up (mean = 7months). CONCLUSION: The size and degree of injury has important implications in the optimal surgical management of TRCHs. These operative grades effectively direct surgical care for these rare and complex injuries.

Bringing to Light Symptoms and Treatments of Effort Thrombosis (Paget-Schroetter Syndrome) in the Military Population, a Case Study.

BACKGROUND: Effort thrombosis, or Paget-Schroetter Syndrome, is an activity-induced upper extremity deep vein thrombosis affecting the axillary and/or subclavian vein. It is a rare disorder affecting 2 per 100,000 person years and mainly occurring in young, active individuals after repetitive upper extremity exertion. Effective diagnosis and management of this disorder has been difficult to study given the syndrome's rarity. METHODS: We discuss and evaluate the case of a 38-year-old muscular male Marine who presented to the primary care clinic following an incorrect diagnosis during an emergency room visit where he was evaluated and treated for a right pectoralis muscle strain while having symptoms suggestive of upper extremity vascular congestion, including pain and edema. FINDINGS: Given this presentation in a concentrated population such as the military, the primary care provider's suspicion of effort thrombosis was heightened. This patient was directed for lab and radiology examination followed by vascular surgery evaluation to be treated with catheter-directed thrombolysis, anticoagulation, and a first rib resection. DISCUSSION: Though rare, effort thrombosis is of particular importance in our relatively young, athletic population. A missed or delayed diagnosis could lead to lifelong disability. Awareness of this condition's presentation, inciting factors, and potential sequelae is important to minimize mortality and morbidity.

Ribcage kinematics during exercise justifies thoracoscopic versus postero-lateral thoracotomy lobectomy prompt recovery.

OBJECTIVES: The video-assisted thoracic surgery (VATS) approach is encouraged over postero-lateral thoracotomy (PLT) for lobectomy in lung cancer. We compare the ribcage kinematics during exercise before and after both procedures, assuming that VATS, being minimally invasive, could better preserve ribcage expansion. METHODS: Thirty-one patients undergoing lobectomy by means of VATS (n = 20) or PLT (n = 11) were compared presurgery, after chest drainage removal (T1) and 2 months post-surgery (T2) during quiet breathing and incremental exercise. Spirometry, chest pain, ventilatory pattern and expansions of the ribcage (ΔVRC) and abdomen were measured. Furthermore, the expansion of the ribcage and abdomen in the operated (ΔVRC-OP and ΔVAB-OP, respectively) and non-operated (ΔVRC-NO and ΔVAB-NO, respectively) sides was also considered. RESULTS: At T1, in both groups, spirometry worsened and chest pain increased, being higher after PLT. Tidal volume (VT) decreased after PLT because the ribcage expanded less due to reduced ΔVRC-OP. Contrary to this, in VATS, there were no changes in VT and ΔVRC, although ΔVRC-OP was lower, because ΔVRC-NO increased at high level of exercise. At T2, ΔVRC-OP was completely restored after VATS. At high levels of exercise following PLT, although patients still showed reduced ΔVRC and ΔVRC-OP, VT was restored owing to increased ΔVAB-NO. CONCLUSIONS: We demonstrate VATS to have a reduced impact on ribcage kinematics while PLT induced restriction more markedly during exercise and still present 2 months after surgery. Patients adopt 2 different compensatory mechanisms, by shifting the expansion toward the contralateral ribcage after VATS and toward the abdomen after PLT. Our study justifies thoracoscopic lobectomy prompt recovery. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov (NCT02910453).

Surgical Management of the Radiated Chest Wall and Its Complications.

Radiation to the chest wall is common before resection of tumors. Osteoradionecrosis can occur after radiation treatment. Radical resection and reconstruction can be lifesaving. Soft tissue coverage using myocutaneous or omental flaps is determined by the quality of soft tissue available and the status of the vascular pedicle supplying available myocutaneous flaps. Radiation-induced sarcomas of the chest wall occur most commonly after radiation therapy for breast cancer. Although angiosarcomas are the most common radiation-induced sarcomas, osteosarcoma, myosarcomas, rhabdomyosarcoma, and undifferentiated sarcomas also occur. The most effective treatment is surgical resection. Inoperable tumors are treated with chemotherapy, with low response rates.

Primary Tumors of the Osseous Chest Wall and Their Management.

Primary osseous tumors of the chest wall are uncommon neoplasms. They occur in a wide variety of pathologic forms, most of which can be distinguished by unique radiologic appearance. Management of these tumors depends on the diagnosis and stage. Adequate surgical resection is critical in achieving the best outcomes for most of these tumors. Chemotherapy and radiation may have an adjuvant role. Surgeons considering resection of any chest wall tumor should have a sound knowledge of the principles of resection and reconstruction.