RU2158556C2 - Method for performing thoracoplasty in the cases of sternum bifidum (schistosternia) - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves releasing sternum defect by separating skin with subcutaneous fat and fascia. Sternum edges are freshened by forming soft tissue flaps. Split portions of the sternum are brought together to reach normal cross-sizes of the sternum and correct normal spatial orientation of the clavicles. Subperiosteally resected bone fragment of the iliac bone wing with a part of apophysis is placed into the residual sternum defect. Sternum edges contact plane engaged with auto transplant is covered with soft tissue flaps. EFFECT: enhanced effectiveness of treatment. 2 cl, 1 dwg

Description

 The invention relates to orthopedics and thoracic surgery.

 The known method, selected as a prototype, surgical correction of congenital cleavage of the sternum (pediatric surgery. T.1 / Under the general editorship of K.U. Ashcraft and T.T. Holder, - St. Petersburg: Hard-Ford Publishing House, 1996) .

 The essence of this method is as follows: a longitudinal skin incision is carried out over the entire length of the defect. Immediately below the subcutaneous layer, split fragments of the defective sternum with pectoral muscles extending from their lateral surfaces are determined. Immediately below them are the endothoracic fascia and pericardium. The endothoracic fascia is separated posteriorly from the sternum on both sides by blind preparation so that sutures can be safely applied. The rapprochement of the sternal plates is facilitated by the wedge-shaped excision of the cartilage in the lower section. Then, suturing of the Tev-dek defect or 2-0 polydioxin sutures is performed.

The disadvantages of this method is the prototype surgical correction of congenital cleavage of the sternum are:
1. The difficulty of use in children older than 1 year because of the danger of reducing the size of the chest and compression of the heart. If during the newborn period the chest is flexible and supple, then at an older age it becomes relatively elastic and when the split sternum is stitched together, especially with large defects, the rib cage decreases in size, exerting significant pressure on the heart, thereby creating adverse conditions for its functioning .

 2. The inability to form the optimal transverse dimensions of the sternum and chest, because prototype method involves the rapprochement of mobilized "halves" of the sternum edge to edge. Therefore, a standard surgical intervention is performed, due to the size of the congenital defect of the sternum.

 3. The absence of a given directed growth of the sternum in height, which is due to the underdevelopment of the upper segment of the sternum body, the anatomical structure of which cannot be restored using the prototype method, ie a simple rapprochement of the mobilized "halves" of the split sternum.

 The objective of the invention is the full anatomical restoration of the split (bifurcated) sternum with the formation of optimal sizes and a given growth in height.

 The goal is to improve the quality of treatment and improve the social adaptation of patients.

 This goal is achieved as follows: for the entire length of the defect, a longitudinal skin incision is made in the form of a dovetail. The skin with subcutaneous tissue and fascia is carefully separated, releasing a sternal defect. Its edges on both sides are thoroughly “freshened up” with a sharp scalpel and sharp raspator with the formation of two soft-tissue sheets along the back and front surfaces of the split fragments of the bifurcated sternum. The split fragments of the defective sternum are reduced in such a way as to achieve normal anatomical transverse dimensions of the sternum, the correct spatial orientation of the clavicles and to avoid compression of the heart. On the resulting residual defect of the sternum, a contour template is removed using a sterile metal wire (a thin Kirschner needle).

 The next step on the ilium wing (Fig. 1, pos. 1) according to the template corresponding to the residual sternum defect is a subperiosteal bone fragment with a part of the apophysis (Fig. 1, pos. 2). The resected fragment (bone-apophysial autograft) of the ilium wing, after preliminary marking and passing through it and split fragments of the sternum of the dacron threads, is placed in the residual sternum defect (Fig. 1, pos. 3) with the direction of the apophysis (Fig. 1. pos. 4) up. In order to prevent gross bone-cartilaginous growths, the contact plane of the bone-apophysial auto-transplant and the split fragments of the sternum on the posterior and anterior surfaces are overlapped by soft-tissue flaps (Fig. 1, position 5) formed during the “refreshment” of the edges of the sternum defect. After that, lavsan threads are pulled and tied (Fig. 1, pos. 6), stably fixing the bone-apophysial autograft to the sternum. The wound is sutured in layers tightly with the application of an intradermal cosmetic suture with a monofilament thread.

CLINICAL EXAMPLE
Patient Olya Ya., 3 years old, was admitted to the clinic (IB No. 2689) with complaints of the presence of splitting of the sternum and bulging in the cleft of soft tissues from birth, which increases with the cry and cry of the child.

 An examination revealed longitudinal splitting of the sternum, going from the jugular notch through the sternum to the xiphoid process. The size of the bone defect of the sternum at the level of its handle is 7 cm. In the area of the defect under the skin, the pulsations of the heart are visually and palpated.

 July 27, 1995 the operation was performed. A longitudinal skin incision in the form of a dovetail over the entire length of the sternum defect. The sternum is represented by two narrow fragments with a width of 0.8-1.0 cm. The edges of the sternum defect are carefully “refreshed” with the formation of two soft-tissue sheets along the posterior and anterior surfaces of the split fragments of the sternum. After that, the fragments of the bifurcated sternum are stitched with lavsan threads and reduced to the required transverse size, taking into account the correct spatial orientation of the clavicles and the absence of the effect of compression of the heart. On the residual defect of the sternum in its upper part, an outline template measuring 2.5 x 2 x 3 cm was removed using a thin Kirschner needle.

 A linear skin incision above the wing of the right ilium. On the iliac wing, a triangular-shaped fragment with a part of the apophysis was resected subperiostally using a metal template corresponding to a residual sternal defect. The resected fragment of the ilium wing is placed in the residual sternal defect with the apophysis pointing upward with the aim of further sternal growth in length as the child grows. The contact points of the bone-apophysial autograft and the split fragments of the sternum along the posterior and anterior surfaces are covered by soft-tissue flaps formed during the “refreshment” of the edges of the sternum defect. A bone autograft is rigidly fixed to the edges of the residual sternal defect with dacron threads. The wound was sutured in layers tightly with the application of an intradermal cosmetic suture with a monofilament thread. Postoperative course without complications, wound healing occurred by primary intention.

 The patient was examined 1.5 years after surgery. There are no complaints. Leads an active lifestyle. Parents are satisfied with the result of the operation. There are no signs of a relapse of the sternum splitting, the chest is of the correct form.

The claimed invention can be used in orthopedics and in comparison with the prototype has the following advantages:
- the possibility of a full anatomical restoration of the split (bifurcated) sternum with the formation of optimal transverse dimensions of the sternum, spatial orientation of the clavicle, while the prototype when stitching the split sternum reduces the costal skeleton, because mobilized halves of the sternum approach edge to edge, the spatial orientation of the clavicles is also disturbed,
- creating the possibility of a given direction of sternal growth in height due to the growth potential of the apophysis of the autologous bone autograft of the ilium wing, which, combined with the optimal size of the sternum and rib cage, allows for a pronounced positive cosmetic effect, while according to the prototype with a simple approach of the mobilized fragments of the split sternum there is no specified direction of sternum growth in height, which is due to the underdevelopment of the upper segment of the sternum body, the anatomical structure of which o can not be recovered using the process according to the prototype, wherein the cosmetic defect occurs, i.e. narrowing of the chest, reducing its height,
- elimination of the danger of compression of the heart and the creation of optimal conditions for its functioning, while according to the prototype the rib cage is reduced in size, exerting significant pressure on the heart,
- the operation according to the proposed method can be performed at any age and at any severity of the defect, while according to the prototype, the operation is best performed during the neonatal period, when the chest is flexible and supple, i.e. up to 1 year
- prevention of gross bone-cartilaginous growths due to overlapping of the plane of the bone-apophysial autograft and sternum with periosteal-fascial flaps, while according to the prototype, this defect is not excluded,
- a section in the form of a dovetail allows you to fully open the area of surgical intervention and to freely mobilize split fragments of the sternum, and to carve out full fascial-periosteal flaps along the posterior and anterior surface of the sternum to overlap the bone suture plane, and according to the prototype, with a simple longitudinal section, the operative access zone narrows , in connection with which significantly increased trauma to soft tissues.

 The inventive method of thoracoplasty with congenital cleavage (bifurcation) of the sternum is of interest for orthopedics and thoracic surgery, because allows you to form an anatomically full sternum of optimal size and a given height height and improve the social adaptation of patients.

Claims (2)

 1. The method of thoracoplasty with congenital cleavage of the sternum, including an incision, separation of the fascia, rapprochement of the split sternum, characterized in that the rapprochement is carried out until normal transverse dimensions of the sternum and the correct spatial orientation of the clavicles, and then a subperiostectally resected bone fragment of the iliac wing is placed in the residual sternum defect bones with a part of the apophysis, and the apophysis is directed upward, and the plane of contact of the bone-apophysial autograft and split fragments of the sternum The back and front surfaces are covered with soft-tissue flaps formed during the refreshment of the edges of the sternum defect.  2. The method of thoracoplasty with congenital cleavage of the sternum according to claim 1, characterized in that the skin incision is performed in the form of a dovetail.