Outcomes of primary repair of sternal cleft defects: Providing a "bony cover"

Abstract

Background: Sternal clefts are rare congenital anterior chest wall defects created by a lack of midline thoracic fusion. Various surgical repairs have been proposed to provide protection to underlying viscera in these defects.

Aim: This study aims to perform primary sternal cleft repair using techniques, leading to the provision of a complete bony cover and to assess their outcomes on follow-ups.

Materials and methods: During 2009-2020, seven patients were referred to our unit with sternal defects. Out of them, four infants with sternal clefts underwent primary repair using bilateral perichondrial flap creation of the sternal bars and sliding costal chondrotomy at our institute. In one of them with a wider defect, bilateral "intraperiosteal" sliding clavicular osteotomy was additionally performed to achieve tension-free closure.

Results: Satisfactory surgical outcomes were achieved with an uneventful postoperative period. On follow-up, all four patients are thriving well and have a stable anterior chest wall. Those with follow-ups longer than 5 years showed evidence of bone formation.

Conclusion: Bony cover to the heart can be provided in all varieties of sternal cleft defects using primary surgical repair early in infancy. The delay in surgical correction increases the complexity of the procedure and may require the use of prosthetic material which has its own disadvantages.

Keywords: Inferior cleft; Superior cleft; intraperiosteal osteotomy; perichondrial flap; sliding chondrotomy.

Figure 1

Schematic representation to perform sliding costal chondrotomy and clavicular osteotomy. (a) 2-0 silk suture is looped around the rib after opening the perichondrium and then creating space in between the rib and perichondrium (inset box). This maneuver is additionally repeated for periosteum over clavicles for wider defects. V-shaped wedge tissue excised from the xiphoid region (dotted lines). (b) Sliding chondrotomy and osteotomy were performed on both sides in an oblique manner (dashed line), in the second to fifth ribs and clavicle, respectively. (c) The arrow shows the direction of the rib being pulled medially without completely losing contact with its lateral counterpart during the medial approximation of sternal bars

Figure 2

Schematic representation to perform sliding costal chondrotomy and clavicular osteotomy (continued) (a) Transverse cut sections of the sternal bars show perichondrial flaps being raised using endarterectomy dissectors along the dashed line and are mobilized medially as shown by curved arrows. (b) Perichondrial flaps, hence, raised are approximated in the midline using interrupted 5-0 polyglactin sutures. This is assisted by anterior traction applied in the direction of the arrow on the 2-0 polyethylene sutures placed around both sternal bars. (c) All four 2-0 polyethylene peristernal sutures are tied to facilitate sternal bar approximation. The perichondritis and periosteotomy on both sides are closed using interrupted 5-0 polydioxanone sutures. Strap muscles are also approximated in the midline

Figure 3

Follow-up of case 2 after 8 years postoperatively. (a) Well-healed midline scar. (b) CXR with modified PA-RAO view showing calcified margins (white arrows) of the newly formed sternum. (c) CT image at T4 level showing a sternal body growth, covering the defect as compared to preoperative CT image showing the sternal cleft defect at the same level (d). CXR: Chest X-ray, CT: Computed tomography, PA-RAO: Posteroanterior-right anterior oblique