Sternum Reconstruction with a Triple Mesh Technique

Abstract 

The sternum is an important component of the axial skeleton. Its intactness and stability are important not only for respiratory or chest mechanics, but also for mediastinal and hemodynamic stability. Sternal reconstruction may be difficult with extensive tumor and resection of the sternum with a risk of morbidity after surgery. This article presents the case of a forty-year-old male patient who underwent sternal resection and reconstruction for sternal chondrosarcoma using a triple mesh technique. 

The titanium mesh was sandwiched between two polypropylene meshes. It gives more stability and the desired rigidity for the chest wall after extensive anterior chest wall resection. 

Introduction 

Malignant sternal tumors carry the risk of recurrence after surgery, so extensive resection of the anterior chest wall with a safety margin is important. A surgeon’s experience usually determines the selection of the procedure. There is a reported case similar to this, but in that one the surgeon prefers the sternal plate between two polypropylene mesh (1). 

Patient Presentation 

The patient is a forty-year-old man with anterior chest pain who had a parietal pattern and trivial presternal swelling. 

The patient sought medical advice for several months, but his real pathology was overlooked for almost a year, and several analgesic prescriptions were given to him, as the patient’s symptoms were misdiagnosed as musculoskeletal pain. 

A chest Xray and chest CT were eventually done, and they revealed a huge sternal swelling of 8×6 cm. A Tru-Cut needle biopsy was taken, and it revealed devitalized osteochondral tissue with increased cellularity and high suspicion for cartilaginous tumor. 

The decision was made to perform radical resection of the tumor with safety margin and reconstruction of chest wall. 

Operative Techniques 

The patient was placed in the supine position, and the skin was demarcated to illustrate the boundaries of the tumor as well as the sternal landmarks. The patient was painted with betadine and draped. A skin incision similar to that of median sternotomy was performed. 

The skin and subcutaneous tissues were dissected as a flap to expose the underlying tumor. Then the demarcation of skin tumor was done using diathermy. 

Both the internal mammary arteries were ligated and clipped at the level of the sternal angle. Then the tumor was excised carefully using pneumatic oscillating saw. It was then resected along with the overlying pectoralis major muscle. 

A suction drain, along with the right chest tube, was placed. Then the first polypropylene mesh (Ethicon polypropylene mesh 30×30 cm; Johnson, India) was placed after trimming it to fit the area of the defect. It was sutured inferiorly to the rectus sheath and muscle, superiorly to the manubrium sterni, and circumferentially to the ribs and the intercostal muscles. 

Then the second layer of titanium mesh (Pure Titanium Mesh Sheet 1.5/0.6 206×123 mm; Biomet Microfixation, Jacksonville, USA) was placed over the first polypropylene mesh and fixed by several screws (Cancellous cross-drive locking 2×14 mm titanium screws; Biomet Microfixation, Jacksonville, USA). About six screws were used on each side of the ribs on both sides. The manubrium was fixed superiorly using three screws. 

A few stitches were then taken between the titanium mesh and the underlying polypropylene mesh to abolish any dead space. 

Next, the proximal part of pectoralis muscle was approximated and the defect in the distal part was reconstructed by placing a third layer of polypropylene mesh over the titanium mesh. 

Vancomycin powder was then placed over the titanium mesh, which lessens chance of infection. 

The skin and subcutaneous flap should be freely and well developed to allow for easy closure without tension. 

A few stitches were place between the subcutaneous tissues and the underlying Prolene mesh to minimize the dead space. 

The patient was then extubated on the table with no respiratory compromise or paradoxical movement. He was admitted in the intensive care for only twelve hours for meticulous follow-up and observation and then discharged to the ward. The patient returned home four days later with trivial pain, a stable chest, and no significantly obvious deformation of the chest wall, which is another advantageous point. 

The histopathological examination of the tumor revealed conventional chondrosarcoma grade 3, a large area of necrosis (50 percent of examined tumor), and free surgical margins of the bone. The decision made at the postoperative multidisciplinary team conference was to send the patient for chemotherapy. 

Outcome and Discussion 

Chest wall reconstruction is important to prevent any chest wall defect after surgery that may lead to a floating chest wall, mediastinal flutter, and cardiopulmonary compromise. 

Because of lack of consensus regarding the selected material for sternal reconstruction, different materials can be used mostly according to the surgeon’s level of experience. 

According to a study performed by Zhang et al. in using the titanium mesh in sternal reconstruction in a group of eight patients, titanium mesh is convenient for rebuilding sternal defects, and it matches the hardness and elastic properties of bone (2). Moreover, titanium is noncarcinogenic, nonallergenic, and offers high strength and good biocompatibility (2). 

The most common complication after sternal reconstruction is the fluid that surrounds the implant that can lead to secondary infection and operation failure. That is why the authors of this article tried to avoid that by a utilizing a good hemostasis and putting in two suction drains (one above and one below the titanium mesh), as well as a few stitches between the titanium mesh and the two polypropylene meshes to abolish any dead space. 

There was no fear regarding the use Prolene mesh and its adhesions because it is isolated from the heart by the pericardium and the mediastinal fat. 

To sum up, triple mesh technique, with the titanium mesh in particular, achieves a very satisfactory result, which includes:  

1. Restoration of intactness and stability of the chest wall to preserve chest mechanics  
2. Achievement of the desired rigidity of the chest wall particularly of that vital portion of the chest wall which overlies the heart and mediastinum 
3. Reformation of the chest shape with not much deformity, which was very appreciated by the patient upon follow-up 

Acknowledgements 

The authors would like to acknowledge for their support and encouragement for creation of this endeavor: 

Professor Ahmed El-Minshawy, professor of cardiac surgery and vice president for graduate studies and research, Assiut University, Egypt 

Professor Ahmed Ghoneim, our chief of the cardiothoracic surgery, 

Professor Dalia Ahmed Elsers, professor of pathology, Assiut University 

Dr. Safaa Sayed Amer, medical representative in Zimmer Biomet 

References

1. Matsumoto K, Sano I, Nakamura A, Morino S, Yamasaki N, Tsuchiya T, et al. Anterior chest wall reconstruction with titanium plate sandwiched between two polypropylene sheets. General Thoracic and Cardiovascular Surgery. 2012;60(9):590-
2. Zhang Y, Li J-z, Hao Y-j, Lu X-c, Shi H-l, Liu Y, et al. Sternal Tumor Resection and Reconstruction with Titanium Mesh: a Preliminary Study. Orthopaedic Surgery. 2015;7(2):155-60.

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