RU2166292C1 - Method for treating the cases of pectus carinatum - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying surgical intervention to correct the deformity. The chest is mobilized by means of segmental bilateral resection of II-VII ribs in parasternal region 0.5 cm apart from the sternum. Rib chondrotomy is carried out 1.0-1.5 cm medial relative to osteochondral area boundary at the place the rib segments are deformed most of all. Wedge-like sternum resection and sternotomy are carried out. Sternocostal complex is to be fixed under tension with perforated titanium plates arranged on the anterior surface of skeletted sternum and ribs. EFFECT: prevented recurrence; eliminated primary pathogenetic causes of the deformity. 6 dwg

Description

 The invention relates to medicine, namely to orthopedics, in particular to methods for surgical correction of keeled chest deformity.

 Keeled chest deformity (CDHC) is a malformation that manifests itself in a different in shape and size protrusion of the anterior chest wall. KDGK, according to OV.Dolnitsky, L.I. Dirdovskaya, 1978; G.A. Bairova, A.A. Fokina, 1983; G. Oelsnitz, 1983, accounts for 6 to 22% of all congenital deformities of the chest. The latter are found in approximately 1% of people.

 To treat this defect, surgical methods are used, which are usually used for cosmetic reasons. In the literature, this problem is not adequately covered, apparently, due to rarely encountered deformation.

 Currently, more than 10 different thoracoplasty techniques are used for keeled chest deformities. According to the literature, the number of relapses of this defect in the postoperative period is from 5 to 10% (N.I. Kondrashin, 1997).

 The first operation for FGC in 1953 was performed by Lester. He used a sub-periapical resection of the costal cartilage involved in the deformity, combining it with a subperiosteal resection of the entire sternum.

 In 1958, Chin proposed resection of cartilage of the VI and VII ribs. Next, the subperiosteal resected the V-shaped segment of the sternum body to level IV rib. Then a previously cut xiphoid process with rectus abdominis was sutured here. The author suggests that the tension of the stitched muscles causes the sternum to lower (cited by O. V. Dolnitsky and L. I. Dirdovskaya. Congenital deformity of the chest in children. - Kiev: Health, 1978. - P. 90-100).

 In children, M. M. Ravitsh used the method of treating keel-like chest deformity described in Congenital deformities of the chest Wall and their operative Correction, Surgery, Philadelphia, 1977,. VI, 306.

 The author used transverse sternotomy of the anterior plate of the sternum at the level of the III rib. All deformed costal cartilages were resected subperitoneally from the IV to VIII ribs on both sides after cutting off the xiphoid process from the sternum. Then he applied multiple wrinkled in the form of accordion nodal seams on the perichondrium of the removed ribs. After that, in a corrected position, he stitched the sternum and the perichondrium of the resected ribs was sutured to it to create a single framework of the anterior chest wall.

The studies of patent literature revealed methods and devices for the treatment of keeled chest deformity:
A.S. N 963512 IPC A 61 B 17/00, B.I. N 37, 1982, protected by NI Kondrashin “Method of thoracoplasty of keeloid deformity of the chest”, consisting in the separation of the pectoral muscles from the sternum and ribs, the osteotomy of the xiphoid process with the rectus abdominis muscles, the sphenoid osteotomy of the sternum at the level of 1-11 intercostal space and longitudinal resection her, departing 0.5 cm from the place of attachment of the ribs, followed by the intersection of II-VII ribs on both sides at the junction of the cartilage in the bone. After this, the transected ribs are transposed together with the remaining bone plates of the sternum body to the center, the resected sternal edges are combined with the ribs and sutured with Dacron threads with 11 ribs attached to the sternum handle. The xiphoid process with the rectus abdominis and pectoral muscles are sutured to the remnants of the sternum.

 The author operated on 5 patients with keeled chest deformity. All received good cosmetic results in follow-up periods of up to 3 years. The operations were performed in patients 16-19 years of age.

 A significant drawback of all of the above methods of treating CDHC is the high invasiveness of surgery associated with total or subtotal resection of the sternum and costal cartilage. But the main point in the development of chest deformities is the genetically determined dysplasia of the costal cartilage. Deformation of the sternum is secondary. Therefore, there is no need to conduct operations at FGC in such a volume.

 Prevention of recurrence of deformity during the period of growth of the child should be aimed at long-term fixation of the sterno-costal complex (GRC) brought to the correction position.

 A. s. N 1475627 IPC A 61 17/58, B.I. N 16, 1989 protected by P.T.Syagailo, L.I. Boyko and A.P. Syagailo “Device for correction of keel-shaped chest deformity”, which contains a curved support plate fixed to the chest using grips, correction units in the form threaded rods with bone clamps, spring-loaded to create a metered load on the deformed sections of the ribs, a guide bar with holes for accommodating correction nodes and mounted on the base plate with the help of adjusting bolts. After sternotomy and chondrotomy of the ribs, a device is installed and a gradual dosed correction of the chest is performed within 10-14 days. The device is removed after 3-6 weeks.

 Positive in this method of treatment is the fixation of GRK for 1-1.5 months until the complete consolidation of the crossed ribs and sternum, a slight invasiveness of the surgical intervention.

The disadvantages of the proposed method for the treatment of keeled chest are:
1. Inadequate mobilization of the sterno-costal complex (ribs intersect only at the border of the bone-cartilaginous part) leads to tension of the bone-cartilaginous structures of the anterior chest wall with a tendency to return to its original position, which creates the prerequisites for relapse;
2. The possibility of infection in places of bone supports of the device with the development of purulent complications in the postoperative period;
3. Perforation of the cartilaginous part of the rib in the region of the bone fixative due to the development of cartilage resorption due to constant pressure with loss of correction and the occurrence of pneumothorax.

 The closest technical solution is the method of thoracoplasty with CDGC according to G.A.Bairov and I.A. Marshev, described in the book by M.L.Dmitriev, G.A. Bairov, K.S. Ternovoy, L.V. Prokopova "Osteoplastic operations in children "- Kiev: Health, 1974. - S. 234-235, which is taken as a prototype.

 According to this method, a transverse wave-like section of 10-15 cm is carried out over the middle section of the deformation. Mobilize the skin with subcutaneous tissue on both sides of the incision, widely freeing the keel-like protruding section of the ribs and sternum. The xiphoid process and partially the rectus abdominis are cut off, pulling them down. 10-20 ml of a 0.25% solution of novocaine are injected over the sternum and the pleural sheets and pericardium are peeled off from the inner surface of the sternum and ribs in a blunt way. Then, V-VIII ribs are excised on both sides from the top of the retraction, 1-1.5 cm long, together with the anterior part of the perichondrium (periosteum). Resect on top of the "keel" 1-2 cm of the sternum. With its retraction in the lower section, under the control of a finger, the outer plate of the bone is crossed at the curvature border, and the posterior plate is broken. Crossed ribs and sternum are sutured with separate nylon seams, the wound is sutured in layers. A pressure bandage is applied.

 The sutures are removed on the 10-12th day, the pressing adhesive bandage is left in children 5-8 years old for 14-17 days, and in older ones - for 24 days.

The disadvantages of this method of thoracoplasty KDGK are:
1. Inadequate mobilization of GRK - a resection of the concave cartilaginous parts of the ribs and sternum at the apex of the protrusion is performed, and with corpuscostal and costal types of deformation, the ribs with the sternum form an angle to be corrected. Therefore, it is necessary to mobilize the ribs in the parasternal region;
2. With KDGK ribs have a more horizontal direction than normal. Therefore, to change the costal angle, it is necessary to conduct a chondrotomy at the place of transition of the bone part of the ribs into the cartilaginous;
3. When using this method, the authors cross the V-VIII ribs. Pathogenetically, it is also necessary to perform resection and chondrotomy of the II-IV ribs, especially with the manubriocostal type of deformation;
4. Fixation, which is carried out in the postoperative period with a pressure adhesive bandage, short-term (14-24 days), makes it difficult to examine the chest and dressings, and also limits the excursion of the chest with the occurrence of congestion in the lungs.

 These shortcomings contribute to the development of deformity after thoracoplasty and the occurrence of postoperative complications.

 The aim of the proposed method is the prevention of postoperative complications and the prevention of recurrence of chest deformity.

 The method is as follows.

 The operation is performed in the position of the patient lying on his back under endotracheal anesthesia with mechanical ventilation. The skin is dissected with a transverse submammar wave-like incision and is separated throughout the chest deformity. The pectoral muscles are cut off from the sternum and separated in a sharp and blunt way to the front axillary line. The xiphoid process is cut off and exfoliated along with the rectus abdominis muscles. A subperitoneal parasternal segmental (0.5–2.0 cm) resection of the II-VII ribs is made, 0.5 cm indent from the edge of the sternum (Fig. 1 shows the rib cage in front - 1; Fig. 2 shows a keeled deformed skeleton of the thoracic segment - 1). At 1.0 - 1.5 cm medial from the border of the bone and cartilage of the ribs produce bilateral chondrotomy of the same ribs (Fig. 1,2; Fig.2,2). When determining the retraction of the cartilaginous part of the ribs, if necessary, carry out their additional chondrotomy in the place of the most pronounced deformation (Fig. 1.3; Fig.2.3). In the place of the greatest protrusion of the sternum, its wedge-shaped resection is performed with the base of the wedge anteriorly (Fig. 1, 4; Fig. 3 - depicts a keeled chest in the side - 4). In the place of sternum retraction, an additional sternotomy of the posterior cortical plate is performed (Fig. 1.5; Fig. 3.5), the anterior one is broken. Resected sections of the ribs and sternum are compared and stitched with single lavsan sutures.

 Plates, for example, of titanium 8T1-0 with a thickness of 0.05 - 0.1 cm, a width of 0.5-0.7 cm and a length equal to the distance between the front axillary lines, give a bend in the physiological profile of the anterior chest wall (figure 4 - chest in the correction position with fixing plates on the front surface, 6; Fig. 5 - skeleton of the chest segment in the correction position, fixed to the plates, 6). Each plate has holes with a diameter of 0.1-0.2 cm in the midline every 1.5 cm (Fig. 4.7; Fig. 6 - chest on the side in the correction position with fixing titanium plates, 7). Depending on the extent of the deformation, 2-4 plates are horizontally laid on the skeletonized front surface of the sternum and ribs. Retreating 0.5-1.0 cm from the border of the bone and cartilaginous part of the ribs, hem one of the ends of the plate to the cartilaginous part of the rib (Fig. 4.8; Fig. 5.8), passing the mylar thread or wire through the hole in the plate. The plate is pulled along the profile of the anterior chest wall and in tension is fixed to the same area of the opposite rib. Crossed sections of the ribs and sternum through the holes are also fixed to the plates with single dacron seams. The xiphoid process along with the rectus abdominis is sutured to the body of the sternum. The pectoral muscles are laid in place and sutured with single sutures, thus closing the plates. Layered stitches. The wound is sealed, for example, with a Lifusol aerosol. After the aerosol liquid has dried, the wound is closed with an aseptic dry dressing. For 2 days, the patient is transferred to the intensive care unit. The patient is allowed to walk independently from the 6th day after the operation; they are discharged for outpatient treatment on the 12th day.

 The plates are removed 3-5 years after surgery.

 Example. Patient D., 13 years old, was in the clinic with a diagnosis of keeled chest deformity, corporocostal type, asymmetric shape. Performed sternochondroplasty with fixation of GRK with titanium plates by the proposed method. The patient was operated on under endotracheal anesthesia. The position of the patient on the back. A transverse wave-like incision of the skin, which, together with the subcutaneous tissue, is separated throughout the deformation. The pectoralis major muscles are cut off from the sternum and separated outwards to the anterior axillary line. The xiphoid process is cut off from the sternum and retracted downward along with the rectus abdominis muscles. A segmental subchondral resection was performed over 1.5 cm of the III-VII ribs on both sides, departing from the sternum of 0.5 cm. Chondrotomy of the same ribs was medial 1.5 cm from the border of the bone and cartilage. Additional chondrotomy of the V-VI ribs along the midclavicular line on both sides. Wedge resection of the sternum at the top of the deformity. GRK freely displayed in the correction position. Three titanium plates with holes are laid on the skeletonized front surface of the sternum and ribs and are sewn to the III, V, and VII ribs in tension. Layered stitches. The wound is sealed with a "lifusole" and covered with an aseptic dry dressing. The correction is good. The patient started walking on his own from day 6, was discharged 12 days after surgery.

The advantages of the proposed method of treatment compared to the prototype are:
1. An adequate mobilization of the sterno-costal complex is carried out, during which all the main pathogenetic components of the keeled chest deformity are eliminated;
2. GRK after correction is fixed by transverse perforated titanium plates, modeled by the profile and size of the chest, which is the prevention of relapse in the postoperative period;
3. During fixation with titanium plates, an additional correction of the sternum and ribs is carried out, which maximally approximates the shape of the chest to the ideal;
4. Thin titanium plates are very plastic, easily acquire their desired shape and are shortened with scissors during surgery, and are also freely closed with soft tissues after laying on the skeletonized front surface of the chest;
5. Do not interfere with the growth of the chest, because the plates are fixed outside the growth zone of the ribs, can be used at any age and with different types of CDHCs, preventing the occurrence of relapse in the child.

Claims (1)

 A method of treating keeled chest deformity, involving surgical intervention and correction of deformation with sternotomy, wedge-shaped resection of the sternum and chondrotomy of the ribs, characterized in that the deformed chest is mobilized by segmental bilateral resection of the II - VII ribs in the parasternal region, 0.5 cm from the sternum , chondrotomy of the ribs 1.0 - 1.5 cm medial to the border of the bone-cartilaginous part and in the place of the most deformed sections of the ribs with subsequent fixation in the tension of the sternocostal omplex perforated titanium plates, stacked on the front surface of skeletal sternum and ribs.

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