Titanium Rib Plate Technique for Huge Chest Wall Reconstruction

doi:10.4236/ss.2011.26070

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Surgical Science, 2011, 2, 331-334

doi:10.4236/ss.2011.26070 Published Online August 2011 (http://www.SciRP.org/journal/ss)

Titanium Rib Plate Technique for Huge Chest Wall

Reconstruction

Yong Han Yoon

Department of Th oracic and Cardiovascular Surgery, Inha University College of Medicine, Incheon, Korea

E-mail: [email protected]

Received February 9, 2011; revised April 6, 2011; accepted August 2, 2011

Abstract

Chest wall reconstruction after en-bloc tumor resection is very important to preserve functional mobility and

to enhance the cosmetic effect. Because they are flexible and pliable, titanium plates are proposed to recon-

struct the chest wall, even though such chest wall reconstruction has been performed in only a few cases

worldwide. We present a case of a 49-year-old man with a chondrosarcoma arising from the left 1st rib, in-

vading the manubrium, clavicle, 2nd and 3rd ribs, and the anterior segment of the left upper lobe. After wide

resection, the chest wall was reconstructed using titanium rib plates and Marlex mesh—the Bovine pericar-

dium sandwich type. The patient tolerated the pain well, and fourteen months after surgery, the chest wall

was well preserved function mobility and improved pulmonary function test.

Keywords: Chest Wall Reconstruction, Titanium Plate, Chondrosarcoma

1. Introduction

Generally, chest wall defects larger than 5cm in size, in

any location, and those more than 10cm in size, posterior

or in close proximity to the scapula, must be recon-

structed [1]. LeRoux and Shama [2], proposed that the

ideal characteristics of a prosthetic material are rigidity

to invalidate paradoxical chest wall motion, inertness to

allow in-growth of fibrotic tissue and decrease the like

hood to the appropriate shape at the time of operation,

and radiolucency to allow radiographic follow-up the

underlying problem. Techniques have been developed

for thoracic reconstruction surgery that allows resection

of chondrosarcomas. Wide excision surgical treatment is

the best choice for chondrosarcoma, after which local-

ized recurrence is the most common problem. Titanium

plates have sufficient inertness to allow the in-growth of

fibrous tissue [3]. Because rigid titanium plates have

many advantages, we expect to use them widely for chest

wall reconstruction.

2. Method

Case Report

A 48-year-old man was referred for evaluation of chest

pain and a palpable chest wall mass. A chest computed

tomography (CT) scan showed a large mass involving

the left upper lobe, 1st rib, and chest wall, originating

from a well-defined 12.6 × 10.1 cm chondrosarcoma in

the anterior chest wall (Figures 1(a) and (b)). A local-

ized chest wall biopsy showed a spindle cell sarcoma.

The chest wall mass was resected. The wide excision

was performed and included soft tissue, partial manu-

brium, clavicle, the 1st-3rd ribs, and anterior segment of

the left upper lobe without any problems. The surgical

margin had to be free of tumor by frozen section before

the reconstructive procedure was attempted. Skeletal

reconstruction surgery was performed, including the

manubrium, clavicle, and 1st-4th ribs. We used a latis-

simus dorsi muscle flap associated with a split thickness

skin graft. The pathology results revealed a dedifferenti-

ated chondrosarcoma sarcoma, the 1st rib was a rhado-

myosarcoma and cell necrosis extension into the inter-

costal soft tissue invaded the lung parenchyma and

manubrium that was 16.0 × 11.0 × 11.0 cm in size. The

patient was discharged uneventfully on post-operative

day 24 and underwent radiotherapy.

3. Surgical Tech nique

Five rib plate surgery of the anterior chest wall was per-

formed after resection of thechest wall chondrosarcoma,

Y. H. YOON

332

(a) (b)

Figure 1. (a) Chest computed tomography scan showing the huge mass involving left upper lobe, 1st rib and chest wall; (b)

chest computed tomography scan showing the huge mass involving left anterior chest wall with sternum and left upper lobe.

Figure 2. Intra-operative view of chest wall reconstruction,

there was performed by double Marlex mesh-Bovine peri-

cardium and multiple titanium rib plate.

partial clavicle, 1st, 2nd, and 3rd ribs, and the segmentec-

tomy of the left upper lobe with severe adhesions be-

tween the chest walls mass and left upper lobe. We used

a double Marlex mesh-Bovine pericardium composite to

repair large defects involving the sternum and anter-

olateral chest wall that protect the underlying cardiovas-

cular structures. The prosthesis was sewn with inter-

rupted non-absorbable suture (2-0 Ethibond). Five rib

plates were inserted between the 1st, 2nd, 3rd, and 4th ribs,

clavicle and manubrium (Figure 2). After the skeletal

reconstruction was completed, the second phase of the

chest wall reconstruction was performed with an interpo-

sition of large muscle and skin flaps.

Postoperative Recovery

The patient was discharged uneventfully on post-opera-

tive day 24 and underwent radiotherapy (Figure 3). The

pulmonary function test results before and 4 months after

surgery showed the following: vital capacity, 2.60 and

2.72 liter; 67% and 65%; forced expiratory volume in 1

Figure 3. 3D chest wall computed tomography showing

reconstructed left upper thoracic cage by multiple prosthe-

sis and screw.

sec, 2.17 and 2.33 liter; 67% and 71%. Fourteen months

after surgery, the patient was doing well and had im-

proved pulmonary function tests.

4. Discussion

Synthetic mesh (Prolene mesh, Gore-Tex, or Marelx

mesh), methyl metacrylate, and a muscular flap are fre-

quently used for chest wall reconstruction. Even though

its safety has been studied and favorable results have

been obtained [4-6], these meshes are too weak for lat-

eral chest wall reconstruction [7]. Methyl methacrylate,

popular in United States, can create good chest wall sta-

bility, but some problems have been reported in the

Y. H. YOON333

preparation and adaptation to the shape of the defect [1].

Coonar et al. have reported on the advan tages of titanium,

including a high strength-to-weight ratio, osseointegra-

tion, and less interference with computed tomography

than higher density metals have. A reduced rate of com-

puted tomographic artifacts allows for more accurate

three-dimensional reconstructions. Titanium is not fer-

romagnetic, so it can be used safely with magnetic reso-

nance imaging [8]. In 1997, Nomori et al. performed

chest wall reconstruction with a titanium hollow screw

plate in a patient with squamous cell carcinoma invading

the 2th-4th ribs [9]. The defected 3rd and 4th ribs were re-

constructed with rib-to-rib titanium plates. At that time,

meshes, such as PTFE patches, metal plates, and silastic

sheeting were popular with reconstructing huge chest

wall defects. We suspect those types of reconstructions

presented very challenging trials, since there were no

other published reports of titanium plate use in chest wall

reconstruction for more than 10 years. In the past 2 years,

a few excellent cases reports were published. Gonfiotti et al.

operated on a Ewing’s sarcoma patient: two STRATOS

(Strasburg Thoracic Osteosyntheses System; MedXpert,

Heitersheim, Germany) bars were fixed posteriorly to the

ribs, with the special clips, and anterioly to the edges of

the sternum, with metal wires [1]. Bille et al. operated on

a Ewing’s sarcoma patient with a Gore-tex mesh and

titanium rib prosthesis to reconstruc t the third, fourth and

fifth ribs (Stratos) [7]. Coonar et al. placed four STRATOS

titanium plates, fixed by clips to both sides of ribs. Dur-

ing the 21-month follow-up, there was no recurrence;

also demonstrated were the durability and resistance of

inserted titanium plates through scapular and elbow frac-

tures [8,10]. Iarussi et al. performed 13 chest wall recon-

structions using Synthes titanium plates (Synthes, West

Chester, Pa) but no details were published [11]; even

though they achieved chest cage stability, with only 1

titanium plate insertion in the resected area of the 2nd rib.

Just how this stability was achieved has not been dis-

cussed.

Compared to other reported cases, our patient had a

very large mass; for that reason, extensive reconstruction

from the clavicle to the 3rd rib was performed. Instead of

screws and wires, simpler and more relevant material,

such as clips, likely make it easier to fix plates. We used

titanium plates for the first time for a large chest wall

construction, and we had no difficulty inserting the plates

and we easily understood how they work. We assume

that Titanium plates cause less severe adhesions than

other rigid and non-rigid prostheses. Titanium plate chest

wall reconstruction is not used worldwide but has been

performed in some European countries. To establish the

most effective and optimal procedure, long-term follow

up and multicenter studies will be necessary. Titanium

rib plate is suitable in chest wall reconstruction surgery

for large defect chest walls and facilitates a good quality

of life.

Comparisons between titanium plates and other meth-

ods for cost-effectiven ess, quality of life, convenience of

skill, recurrence rate, and mortality sh ould be analyzed in

near future.

5. Conclusions

Titanium rib plate is suitable in chest wall reconstru ction

surgery for huge defect chest walls and facilitates a good

quality of life.

6. Acknowledgements

This work was supported b y an Inha Univ ersity Research

Gant.

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