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.

[Mediastinal Dedifferentiated Liposarcoma Reconstructing Defected Chest Wall Using Prosthetic Materials:Report of a Case].

Present case is a 74-year-old man, given a diagnosis of huge mediastinal dedifferentiated liposarcoma. Surgical complete resection of the tumor and involved anterior chest wall( all body of sternum and bilateral 3rd~5th rib) followed by reconstruction of the defected chest wall using three artificial prosthetic materials of putting titanium mesh plate between ePTFE mesh seat at inner (mediastinal) site and polypropylene mesh seat at outer site was perfomed. The patient is doing well without respirately failure and disease free even 6 years after surgery. This surgical procedure could be thought of effective treatment method in sense of preventing postoperative complication and preserving respiratory function.

Critical Chest Wall Necrotizing Fasciitis Triggered by Herpes Zoster: A Case Report.

BACKGROUND Necrotizing fasciitis is an aggressive type of skin and soft tissue infection that results in necrosis of subcutaneous tissues, including muscle and fascia. Mixed bacteria, including gas-forming organisms, are usually identified. This report describes a 55-year-old male diabetic patient with herpes zoster involving the thoracic dermatomes complicated by skin infection, necrotizing fasciitis, chest wall abscess, and sepsis. CASE REPORT A 55-year-old man with diabetes mellitus presented with thoracic herpes zoster, initially treated with acyclovir and topical agents. He developed swelling, pain, and fever over the left chest, which was unresponsive to topical treatment. Investigations revealed elevated white blood cells and gas on chest X-ray. Computed tomography confirmed a 13×6×11-cm abscess with gas between the latissimus dorsi and serratus anterior muscles, suggesting necrosis. He received intravenous amoxicillin/clavulanic acid and metronidazole and underwent urgent surgical drainage, yielding 200 mL of pus. Cultures identified antibiotic-sensitive Staphylococcus aureus and Clostridium perfringens. Histopathology confirmed necrotizing tissue with acute bacterial inflammation. He was treated postoperatively with dressings and vacuum-assisted closure, followed by sutures, and was discharged in good condition after 16 days. CONCLUSIONS This case underscores the aggressive nature and potential complications of necrotizing soft tissue infections in patients with diabetes mellitus and herpes zoster. Prompt recognition, early intervention with appropriate antibiotics, and surgical drainage are crucial in managing such infections effectively. The successful use of vacuum-assisted closure therapy underscores its role in facilitating wound healing after debridement. Clinicians should maintain vigilance for necrotizing infections in similar high-risk patients to ensure early intervention and improve clinical outcomes.

Pulmonary mucormycosis eroding the chest wall: challenges in the management.

Pulmonary mucormycosis is a rare, life-threatening fungal infection usually seen in immunocompromised patients. Mortality in such patients is high due to underlying immunosuppression and poor general condition of the patients. Invasion of the adjacent structures is known but, to the best of our knowledge, pulmonary mucormycosis presenting with a full thickness chest wall erosion has not been reported. We report such a case with chest wall destruction with superadded bacterial infection. The use of prosthetic materials for chest wall reconstruction was not possible due to the presence of infection. In addition, there were other intra-operative and post-operative challenges which we managed using a multidisciplinary approach. This report highlights the successful outcome of this complex situation using pre-operative optimisation, adequate surgical debridement and effective management of post-operative complications with patience and perseverance.

Complications of chest wall around malignant tumors: differences based on reconstruction strategy.

BACKGROUND: Malignant chest wall tumors need to be excised with wide resection to ensure tumor free margins, and the reconstruction method should be selected according to the depth and dimensions of the tumor. Vascularized tissue is needed to cover the superficial soft tissue defect or bone tissue defect. This study evaluated differences in complications according to reconstruction strategy. METHODS: Forty-five patients with 52 operations for resection of malignant tumors in the chest wall were retrospectively reviewed. Patients were categorized as having superficial tumors, comprising Group A with simple closure for small soft tissue defects and Group B with flap coverage for wide soft tissue defects, or deep tumors, comprising Group C with full-thickness resection with or without mesh reconstruction and Group D with full-thickness resection covered by flap with or without polymethyl methacrylate. Complications were evaluated for the 52 operations based on reconstruction strategy then risk factors for surgical and respiratory complications were elucidated. RESULTS: Total local recurrence-free survival rates in 45 patients who received first operation were 83.9% at 5 years and 70.6% at 10 years. The surgical complication rate was 11.5% (6/52), occurring only in cases with deep tumors, predominantly from Group D. Operations needing chest wall reconstruction (p = 0.0016) and flap transfer (p = 0.0112) were significantly associated with the incidence of complications. Operations involving complications showed significantly larger tumors, wider areas of bony chest wall resection and greater volumes of bleeding (p < 0.005). Flap transfer was the only significant predictor identified from multivariate analysis (OR: 10.8, 95%CI: 1.05-111; p = 0.0456). The respiratory complication rate was 13.5% (7/52), occurring with superficial and deep tumors, particularly Groups B and D. Flap transfer was significantly associated with the incidence of respiratory complications (p < 0.0005). Cases in the group with respiratory complications were older, more frequently had a history of smoking, had lower FEV1.0% and had a wider area of skin resected compared to cases in the group without respiratory complications (p < 0.05). Preoperative FEV1.0% was the only significant predictor identified from multivariate analysis (OR: 0.814, 95%CI: 0.693-0.957; p = 0.0126). CONCLUSIONS: Surgical complications were more frequent in Group D and after operations involving flap transfer. Severe preoperative FEV1.0% was associated with respiratory complications even in cases of superficial tumors with flap transfer.

[Chest wall reconstruction with a non-rigid synthetic rib prosthesis: a multicenter study]. / Rekonstruktsiya grudnoi stenki nerigidnym sinteticheskim protezom rebra: mul'titsentrovoe issledovanie.

Chest wall resection is performed for a variety of diseases, for primary rib and soft tissue tumors, metastatic lesions, or locally invasive growth of lung and mediastinal tumors being the most common indications. Following the resection phase, it is essential to determine the method of chest wall reconstruction that will restore the structural function, preserve pulmonary biomechanics, reduce the likelihood of residual pleural space, pulmonary hernia, and protect intrathoracic organs. The main objective of this study is to investigate the outcomes of chest wall resection with reconstruction using Codubix material. MATERIAL AND METHODS: This retrospective multicenter study included 22 patients who underwent chest wall tumor resection with subsequent Codubix rib endoprosthesis reconstruction from 2019 to 2023. Four medical institutions participated in the study: P.A. Herzen Moscow Cancer Research Institute, Sverdlovsk Regional Oncology Hospital, Morozov Children's City Clinical Hospital and Kaluga Regional Oncology Hospital. Inclusion criteria were the presence of chest wall tumors, both primary and secondary, removal of more than 2 ribs, resection of the rib arch and the sternum. RESULTS: The median age was 60 years (48-66), 11 (50%) patients were females and 11 (50%) males. Operations for chest wall sarcoma, metastatic lesions, and lung cancer were performed in 9 (40.9%), 4 (18.2%), and 3 (13.6%) patients, respectively. The median number of removed ribs was 3 (2-4), with a maximum of 7. Sternotomy was performed in 9 (40.9%) patients, and subtotal resection of the body or handle of the sternum was carried out in 77.7%. Combined resections were performed in 14 (63.6%) patients. Radical tumor removal (R0) was achieved in 21 (95.5%) patients. Complications were observed in 9 (40.9%) patients, with intermuscular seroma being the most common in three (33.3%), followed by hydrothorax in 2 (22.2%), bilateral pneumonia, acute respiratory failure, and postoperative delirium in 1 (11.1%) patient each. One patient had the Codubix plate removed due to postoperative wound infection. The median overall and recurrence-free survival was not reached, and the 1-year recurrence-free survival was 63.9%, with an overall survival of 86.8%. CONCLUSION: Reconstruction with Codubix material allows for satisfactory functional and cosmetic results, characterized by a low complication rate and good adaptive properties.

The free vastus lateralis-And conjoined vastus lateralis anterolateral thigh/tensor fascia lata flap for oncological chest wall reconstruction.

INTRODUCTION: A reconstructive option for extensive chest wall reconstruction is the free myocutaneous vastus lateralis muscle (VL) flap which can be performed in isolation or in conjunction with a fasciocutaneus anterolateral thigh (cVLALT) and/or myofasciocutaneous tensor fascia lata flap (cVLTFL). We aimed to directly compare the outcomes of these reconstructive options. METHODS: Patients who underwent oncological chest wall reconstruction with a free VL, cVLALT, or cVLTFL flap between February 2010 and 2022 were included in this retrospective study. Patient demographics, surgical characteristics, as well as medical and reconstructive outcomes, were evaluated. The operative outcomes between myocutaneous VL, cVLALT, and cVLTFL flap reconstructions were compared. RESULTS: A total of 41 patients underwent chest wall reconstruction with a free myocutaneous VL (n = 25; 61%), cVLALT (n = 14; 34%), or cVLTFL Three acute flap thromboses occurred in the entire cohort (3/41, 7%), with one myocutaneous VL flap failing because of recurrent venous thrombosis during the salvage procedure. Total flap necrosis was seen in two cases (5%; VL flap: n = 1; cVLALT flap: n = 1), and partial flap necrosis in one VL flap (1/25, 4%) and in the distal ALT portion of three cVLALT flaps (3/14, 21%). No significant difference was seen between isolated VL and conjoined VL flaps regarding the partial (p = .28) or total flap necrosis rate (p = .9). CONCLUSION: The free (conjoined) VL flap provides reliable outcomes for obliterating dead space achieving durable reconstruction of complex chest wall defects.

Three-dimensional modelling and printing in anterior chest wall reconstruction and stabilisation.

Anterior chest wall instability as a result of sternocostal non-union is a rare complication but can give rise to invalidating pain and cardiac arrhythmias. A woman in her 40s was referred to us with anterior chest wall pain and instability after a modified Ravitch procedure. Sternocostal pseudoarthrosis was seen for which multiple operations were performed which were complicated by low-grade infections. A patient-specific three-dimensional modelled and printed prostheses was used in an operation to both lift the sternum for pectus correction and to reconnect the sternum and the sternal costal junction to regain anterior chest wall stability.

Spinal posture, mobility, and position sense in adolescents with chest wall deformities: a comparison of pectus excavatum, pectus carinatum and healthy peers.

PURPOSE: The study aimed to compare spinal posture, mobility, and position sense in adolescents with pectus excavatum (PE), pectus carinatum (PC), and healthy control (HC). METHODS: 22 with PE, 22 with PC, and 21 HC were included in the study. The spinal posture (thoracic kyphosis, lumbar lordosis, pelvic tilt, thoracic, lumbar, pelvic lateral tilt angles) and mobility (thoracic, lumbar, hip/sacral, and overall, in the sagittal and frontal plane) with the spinal mouse, and spinal position sense (repositing errors) with the inclinometer were assessed. RESULTS: The thoracic kyphosis angle of PE and PC was higher than in HC (p < 0.001; p = 0.001). Hip/sacral mobility in the sagittal plane was lower in the PE and PC than control, respectively (p < 0.001; p < 0.001). Overall sagittal spinal mobility (p:0.007) and hip/sacral mobility in the frontal plane (p:0.002) were lower in the PC than in HC. Overall frontal spinal mobility was lower in the PE and PC than in HC (p:0.002; p:0.014). The PE and PC repositing errors were higher (p < 0.001; p:0.014). CONCLUSION: The study found that adolescents with PE and PC had decreased spinal mobility, spinal alignment disorders, and a decline in spinal position sense. It is important not to overlook the spine during physical examinations of adolescents with chest wall deformities. In clinical practice, we suggest that adolescents with chest deformities should undergo a spine evaluation and be referred for physical therapy to manage spinal disorders.

[Surgical treatment of chondromyxoid fibroma of ribs via thoracoabdominal access]. / Khirurgicheskoe lechenie khondromiksoidnoi fibromy reber iz kombinirovannogo torakoabdominal'nogo dostupa.

Surgical treatment of chondromyxoid fibroma of ribs is described. The diagnosis was verified after histological analysis. The patient underwent resection of multinodular tumor of anterolateral thoracic wall invading abdominal cavity via thoracoabdominal access. Postoperative period was uneventful. This case demonstrates the need for total en-bloc resection of tumor with surrounding tissues. Surgery is the only effective method for these patients.

Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass: Impact of Chest Wall Dimensions in Single and Multivessel Bypass.

OBJECTIVE: There can be anatomical constraints on patient selection for minimally invasive surgery. For example, robot-assisted coronary artery bypass was reported to be more challenging when patients had a cardiothoracic ratio >50% and a sternum-vertebra anteroposterior and transverse diameter ratio <0.45. We sought to examine the impact of chest wall anatomic parameters on surgical outcomes in our totally endoscopic coronary artery bypass (TECAB) procedures. METHODS: We retrospectively reviewed patients who underwent robotic TECAB, all of whom had a preoperative chest radiograph at our institution from July 2017 to October 2021. The cohort was divided into 2 groups, which were patients undergoing single-vessel grafting using the left internal thoracic artery (ITA; group 1) and patients undergoing multivessel grafting with bilateral ITA grafts (group 2). We measured several anatomical parameters from the preoperative chest radiograph. RESULTS: A total of 352 patients undergoing TECAB were retrospectively analyzed. After exclusions, 193 were included in this study. In group 1 (n = 91), no parameters correlated with operative time. In group 2 (n = 102), a significant negative correlation was observed between operative time and the sternum-vertebrae anteroposterior diameter (rs = -0.228, P = 0.022) and lung anteroposterior diameter (rs = -0.246, P = 0.013). To confirm these results in group 2, a propensity-matched analysis was performed and showed a statistically significant difference in surgical time based on chest anteroposterior diameters. CONCLUSIONS: In single-vessel robotic TECAB, chest wall anatomic dimensions measured on chest radiograph did not affect operative time. In multivessel cases with bilateral ITA grafts, larger anteroposterior diameter correlated with shorter operative times.

Rheumatoid pleurisy confirmed by biopsy of a chest wall nodule by thoracoscopy under local anaesthesia.

Rheumatoid pleurisy is common in patients with rheumatoid arthritis, but distinguishing it from other diseases, such as heart failure and tuberculous pleurisy, is often difficult. A man in his 70s with stable rheumatoid arthritis presented with cardiac enlargement and bilateral pleural effusion on chest radiography. Pleural fluid studies showed lymphocytosis, adenosine deaminase level of 51.6 U/L and rheumatoid factor level of 2245.3 IU/mL, suggestive of rheumatoid pleurisy and tuberculous pleurisy. Thoracoscopy under local anaesthesia revealed erythema of the parietal pleura, small papillary projections and fibrin deposits. H&E-stained biopsy specimens showed inflammatory granulomas with strong lymphocytic infiltration and non-caseating granulomas. He was diagnosed with rheumatoid pleurisy. His symptoms improved with 30 mg of prednisolone. This study highlights that biopsy using thoracoscopy under local anaesthesia effectively diagnoses rheumatoid pleurisy, which may be challenging to diagnose.

Co-occurrence of posterior chest wall pilonidal sinus with melanocytic nevus: a challenging presentation: a case report.

INTRODUCTION: To date, only a limited number of case reports have documented the co-occurrence of PNS and melanocytic nevus in the medical literature. This study aims to report an exceptionally rare case of posterior chest wall PNS in conjunction with a melanocytic nevus. CASE PRESENTATION: A 46-year-old female presented with a long-standing black lesion on her left upper posterior chest wall, that had become painful in the two months prior to presentation. There was a painful, dark blue, non-erythematous, and non-tender nodule on the left upper posterior chest wall. Based on the patient's desire for cosmetic purposes, the lesion was excised totally with primary closure under local anaesthesia. Histopathological examination revealed intradermal melanocytic nevus with inflamed pilonidal sinus. DISCUSSION: The rarity of posterior chest wall PNS associated with nevi poses unique diagnostic and therapeutic challenges for clinicians. The distinct anatomical location, different from the conventional region, and the rare association between the two conditions may delay accurate diagnosis and result in mismanagement or inappropriate interventions. CONCLUSION: The posterior chest wall PNS is another type of atypical PNS that is extremely rare. The association between PNS and blue nevus is a fascinating medical finding that deserves further investigation.

'Short Bars Crossed' to Remodel the Entire Chest Wall in Children and Adolescents with Pectus Excavatum.

BACKGROUND: The cross-bar technique of minimally invasive pectus excavatum (PE) correction remains underreported, which is especially true of pediatric patients. We therefore reviewed the experience of a Turkish and an Austrian center. An additional novelty characterizing both pediatric cohorts was the use of short bars. METHODS: In a retrospective study, pediatric PE corrections involving 'short bars crossed' were analyzed for complications and intra-/postoperative outcomes. Cases with two or three bars were included, given that a horizontal third bar was placed whenever considered useful for upper-chest elevation. All bars were fitted with a single stabilizer near the surgical entry point. In the Austrian center, intercostal nerve cryoablation was used for pain management. Descriptive statistics are presented. RESULTS: Seventy-eight patients ≤18 years old were evaluable at the Turkish (n = 56) and Austrian (n = 22) centers. Total median values were 16.2 (IQR: 15.1-17.4) years for age and 4.60 (IQR: 3.50-6.11) for Haller index. Ten mild or moderate complications (12.8%) were observed, including just one revision requirement due to bar migration (1.28%). Intercostal nerve cryoablation (n = 13) was associated with longer surgical procedures at 150 (IQR: 137-171) versus 80 (IQR: 60-100) minutes but with shorter hospital stays, given an IQR of 3-4 days versus 4-5 days. CONCLUSION: 'Short bars crossed'-with a single stabilizer in a ventral position close to the surgical entry point-ensure a wide distribution of forces, protect against bar migration, are safe and effective, and offer stability at an age characterized by growth and physical activity. LEVEL OF EVIDENCE: IV.

An atypical case of pediatric anaplastic lymphoma kinase-positive anaplastic large cell lymphoma limited to the skin on chest wall detected by ultrasound.

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