A technique for pediatric chest wall reconstruction using custom-designed titanium implants: description of technique and report of two cases

Abstract

Purpose: We present a surgical technique for chest wall reconstruction using custom-designed titanium implants developed for two female patients to provide both chest wall symmetry and adequate stability for staged breast reconstruction.

Methods: A retrospective review was performed for two adolescent female patients with large chest wall defects who underwent the described technique. The etiology of the chest wall deficiency was secondary to Poland's syndrome in one patient, and secondary to surgical resection of osteosarcoma in the other patient. For each patient, a fine-cut computed tomography scan was obtained to assist with implant design. After fabrication of the prosthesis, reconstruction was performed though a curvilinear thoracotomy approach with attachment of the implant to the adjacent ribs and sternum. Wound closure was obtained with use of synthetic graft material, local soft tissue procedures, and flap procedures as necessary.

Results: The two patients were followed post-operatively for 35 and 38 months, respectively. No intra-operative or post-operative complications were identified. Mild scoliosis that had developed in the patient following chest wall resection for osteosarcoma did not demonstrate any further progression following reconstruction.

Conclusions: We conclude that this technique was successful at providing a stable chest wall reconstruction with satisfactory cosmetic results in our patients.

Keywords: Chest wall deficiency; Chest wall reconstruction; Chest wall resection; Pediatric orthopedics; Poland’s syndrome.

Fig. 1

Oblique view of the three-dimensional model of the prosthesis for reconstruction of the chest wall defect secondary to Poland’s syndrome. Colors represent osteotomized sternum (red), sternal plate (blue), prosthetic ribs (gray and orange), and repositioned second through fifth ribs (green)

Fig. 2

Superior view of three-dimensional model demonstrating the difference between a the native sternum (yellow) and rib position, and b the reconstructed symmetrical chest wall after sternal osteotomy and implant placement

Fig. 3

Intra-operative photograph showing placement of the prosthesis with FiberWire^® sutures securing the prosthesis to the sternum anteriorly and to the sixth rib inferiorly. The Gore-tex^® graft is visible underneath the prosthesis, and the chest tube is located inferiorly. Image oriented with anterior to the right and superior to the top

Fig. 4

Post-operative a anteroposterior and b lateral radiographs demonstrating stable position of the prosthesis

Fig. 5

Frontal (a) and oblique (b) views of the three-dimensional model of the prosthesis for reconstruction of the chest wall defect secondary to osteosarcoma resection, designed to attach to the sternum anteriorly, to the second rib superiorly, to the sixth rib inferiorly, and to the third and fifth rib remnants posteriorly. Colors represent sternum (orange), inferior ribs and vertebra (yellow), superior ribs and vertebra after repositioning with the prosthesis in place (green), rib clips (blue). Suture holes shown as small rods protruding from the anterior sternal plate

Fig. 6

Intra-operative photographs of the patient in the right lateral decubitus position showing a chest wall defect after exposure of sternum and remnant ribs, and b the prosthesis secured in place. Image oriented with cranial to the left and anterior to the bottom

Fig. 7

Post-operative posteroanterior radiograph demonstrating position of the prosthesis. The third rib remnant is visualized superior to the adjacent rib holster. The levoconvex upper thoracic scoliosis curve Cobb angle measures 29°