JBJS | The Use of a Gore-Tex Soft-Tissue Patch to Repair Large Full-Thickness Defects After Subtotal Sternectomy : A Report of Three Cases

The Journal of Bone & Joint Surgery, Volume 83, Issue 3

Case Reports | March 01, 2001

The Use of a Gore-Tex Soft-Tissue Patch to Repair Large Full-Thickness Defects After Subtotal Sternectomy : A Report of Three Cases

Henry F.H. Halm, MD; Christiane Hoffmann, MD; Winfried Winkelmann, MD

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Investigation performed at the Department of Orthopaedic Surgery, Westfälische Wilhelms-Universität, Münster, Germany
Henry F.H. Halm, MD Spine Surgery and Scoliosis Center, Center for Chest Wall Deformities, Klinikum Neustadt, Am Kiebitzberg 10, 23730 Neustadt, Germany.
Christiane Hoffmann, MD Winfried Winkelmann, MD Department of Orthopaedic Surgery, Westfälische Wilhelms-Universität, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 2001; 83:420-420

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Introduction

Introduction | Operative Technique and Results | Discussion | References

Primary tumors of the sternum are rare, accounting for approximately 1% of primary bone tumors¹. Most of these primary tumors are malignant, and the most common lesion is a chondrosarcoma. To avoid local recurrence, it is critical that a wide en bloc resection of the tumor be performed. Management of large defects of the chest wall after resection has remained difficult and controversial². Various methods of reconstruction have been described, including the use of steel bars and Marlex mesh², the use of Marlex mesh with or without methylmethacrylate^3-7, and the use of acrylic resin⁴. When primary wound closure has not been possible, various myocutaneous flaps, including pedicle omental flaps, have been used to close the defect^3,5,6,8-13.

One of us (W.W.) and colleagues first used a Gore-Tex soft-tissue patch in 1992 to close a large chest-wall defect after a subtotal sternectomy that had been performed to remove a large benign chondromyxoid fibroma¹³. That report emphasized the unusual clinical and pathological findings of this rare benign tumor rather than the new operative technique. Since then, we have used Gore-Tex soft-tissue patches to reconstruct a large full-thickness defect of the anterior part of the chest wall after subtotal sternectomy in three additional patients who had a malignant tumor of the sternum (Table I). Two patients had a chondrosarcoma, and one had a sarcoma with rhabdomyosarcomatous differentiation. The latter tumor is very rare and had developed seventeen years after radiation treatment for Hodgkin lymphoma. Two of the tumors were in the body of the sternum, and one was in the manubrium.

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Fig. 1-A:: Figs. 1-A through 1-D Case 3. A thirty-seven-year-old man who had a soft-tissue sarcoma of the sternum. Fig. 1-A Intraoperative photograph showing the large defect remaining after a subtotal sternectomy and wide en bloc resection. Only the cephalad part of the manubrium with the two attached ribs on each side could be preserved.

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Fig. 1-A:: Photographs showing the Gore-Tex patch in place. The patch is attached to the ribs on both sides, the remaining part of the manubrium, and the rectus abdominis and pectoralis major muscles.

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Fig. 1-C:: Photographs, made eight months postoperatively, showing the patient easily lifting a 10-kg weight (Fig. 1-C) and performing a push-up without difficulty (Fig. 1-D).

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Fig. 1-D:: Photographs, made eight months postoperatively, showing the patient easily lifting a 10-kg weight (Fig. 1-C) and performing a push-up without difficulty (Fig. 1-D).

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TABLE I: Preoperative and Postoperative Data

*Secondary malignancy after radiation therapy for Hodgkin disease.

Case	Gender, Age at Op. (yrs)	Size of Specimen (cm)	Histological Type	Location in Sternum	Margin According to Enneking System¹⁵	Durat. of Follow-up (mos)
1	M, 72	17 8 6	Chondrosarcoma, grade 1	Body	Wide	30
2	F, 62	13.5 5 7	Chondrosarcoma, grade 2	Manubrium	Wide	32
3	M, 37	16 8 3	Soft-tissue sarcoma, grade 3*	Body	Wide	24

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TABLE I: Preoperative and Postoperative Data

*Secondary malignancy after radiation therapy for Hodgkin disease.

Case	Gender, Age at Op. (yrs)	Size of Specimen (cm)	Histological Type	Location in Sternum	Margin According to Enneking System¹⁵	Durat. of Follow-up (mos)
1	M, 72	17 8 6	Chondrosarcoma, grade 1	Body	Wide	30
2	F, 62	13.5 5 7	Chondrosarcoma, grade 2	Manubrium	Wide	32
3	M, 37	16 8 3	Soft-tissue sarcoma, grade 3*	Body	Wide	24

Operative Technique and Results

Introduction | Operative Technique and Results | Discussion | References

Awide resection was performed to excise the tumor. In two patients, in whom the tumor originated in the body of the sternum, the xiphoid, body, and residual caudad part of the manubrium were excised along with segments of the attached ribs (Fig. 1-A). In the third patient, the entire manubrium, half of the body of the sternum, and segments of the attached ribs and clavicles were resected.

In the two patients in whom the tumor originated in the body of the sternum, the large anterior chest-wall defect was repaired with a 2-mm-thick Gore-Tex soft-tissue patch that was sutured to the ribs, the rectus abdominis muscles, and the remaining part of the manubrium (Fig. 1-B). In the third patient, the Gore-Tex patch was sutured to the remaining parts of the clavicles, the sternal part of the sternocleidomastoid muscle, and the remaining part of the body of the sternum. Once the Gore-Tex patch was sutured in place, the pectoralis major muscles were reattached to the Gore-Tex patch with resorbable Vicryl sutures (polyglactin; Ethicon, Somerville, New Jersey). The subcutaneous tissue and the skin edges could then be easily approximated.

The postoperative course was uneventful in all three patients, and the wounds healed by primary intention. At the latest follow-up evaluation (twenty-four, thirty, and thirty-two months postoperatively), all three patients were alive and were very satisfied with the result. None of them had signs of local recurrence or distant metastasis.

The functional and cosmetic results were good, and all three patients were able to resume their preoperative level of activity. There was no limitation of the range of motion of either shoulder, and there were no motor or sensory deficits affecting the muscles of the shoulder girdle or the arm. All three patients stated that there were no differences in their quality of life or their lifestyle compared with the preoperative status (Figs. 1-C and 1-D).

Discussion

Introduction | Operative Technique and Results | Discussion | References

Several methods of repairing full-thickness defects of the chest wall after total or subtotal sternectomy have been reported. Most surgeons have used one layer of Marlex mesh or, more recently, two layers of Marlex mesh with a filler of methylmethacrylate, thereby creating a rigid prothesis^2-5,7. A few authors used only myocutaneous flaps^9-11; however, doing so resulted in a loss of function of the muscle that was used in the flap. The ideal procedure requires only the minimum quantity of synthetic material and also avoids interfering with function as is seen with the use of muscle flaps. To the best of our knowledge, the first report on the use of a Gore-Tex soft-tissue patch without additional prosthetic material after subtotal sternectomy was by authors from our institution, in 1993¹³. Since then, we have treated three other patients with this technique. In addition, we are aware of the case of one other patient who had a similar procedure to repair a chest-wall defect after resection of a desmoid tumor of the sternum¹⁴. That patient had an uneventful postoperative course and remained physically active, playing basketball regularly without any limitations. The result in that patient was similar to those in our three patients.

It is difficult to assess the overall risk of complications associated with this procedure because we treated only three patients. However, on the basis of the absence of any complications intraoperatively, in the immediate postoperative period, or during the entire duration of follow-up, we believe that the operative procedure offers a viable alternative to the above-mentioned techniques. Therefore, we recommend the use of a 2-mm-thick Gore-Tex soft-tissue patch to repair full-thickness defects of the anterior part of the chest wall after subtotal sternectomy.

References

Introduction | Operative Technique and Results | Discussion | References

Waller DA, and Newman RJ: Primary bone tumours of the thoracic skeleton: an audit of the Leeds regional bone tumour registry. Thorax,1990.45: 850-5, 45850 1990 [PubMed]

Larsson S; al-Khaja N; and Roberts D: A method for reconstruction of large full-thickness defects of the bony thorax. Scand J Thorac Cardiovasc Surg,1990.24: 33-8, 2433 1990 [PubMed]

Martini N; Huvos AG; Burt ME; Heelan RT; Bains MS; McCormack PM; Rusch VW; Weber M; Downey RJ; and Ginsberg RJ: Predictors of survival in malignant tumors of the sternum. J Thorac Cardiovasc Surg ,1996.111: 96-106, 11196 1996 [PubMed]

Ozaki O; Kitagawa W; Koshiishi H; Sugino K; Mimura T; and Ito K: Thyroid carcinoma metastasized to the sternum: resection of the sternum and reconstruction with acrylic resin. J Surg Oncol,1995.60: 282-5, 60282 1995 [PubMed]

Sabanathan S; Shah R; and Mearns AJ: Surgical treatment of primary malignant chest wall tumours. Eur J Cardiothorac Surg,1997.11: 1011-6, 111011 1997 [PubMed]

Soysal O; Walsh GL; Nesbitt JC; McMurtrey MJ; Roth JA; and Putnam JB Jr: Resection of sternal tumors: extent, reconstruction, and survival. Ann Thorac Surg,1995.60: 1353-9, 601353 1995 [PubMed]

Van Schil PE; Van Look R; Van Calster EL; Van Oosterom AT; and Hauben EI: Sternal resection for primary presternal and retrosternal mediastinal liposarcoma. Eur J Cardiothorac Surg,1996.10: 217-9, 10217 1996 [PubMed]

Chapelier AR; Bacha EA; de Montpreville VT; Dulmet EM; Rietjens M; Margulis A; Macchiarini P; and Dartevelle PG: Radical resection of radiation-induced sarcoma of the chest wall: report of 15 cases. Ann Thorac Surg,1997.63: 214-9, 63214 1997 [PubMed]

Douglas YL; Meuzelaar KJ; van der Lei B; Pras B; and Hoekstra HJ: Osteosarcoma of the sternum. Eur J Surg Oncol,1997.23: 90-1, 2390 1997 [PubMed]

Kiyoizumi T; Takeshita T; and Fujino T: Reconstruction of a large full thickness chest wall defect by a double-folded vertical rectus abdominis musculocutaneous flap. Br J Plast Surg,1989.42: 460-2, 42460 1989 [PubMed]

Shimizu J; Nakamura Y; Tsuchida K; Watanabe S; Tsuchiyama T; Ikebata Y; and Nishimura M.: Complete sternectomy for metastatic carcinoma with reconstruction using a latissimus dorsi musculocutaneous flap. Eur J Cardiothorac Surg.,1995.9: 342-4, 9342 1995 [PubMed]

Telfer JR; Chapple DC; and Powell BW: Metastatic colonic adenocarcinoma in a pedicled omental flap used for sternal reconstruction: a case report. Br J Plast Surg,1996.49: 67-9, 4967 1996 [PubMed]

Wuisman P; Scheld H; Tjan T; Roessner A; Blasius S; Vestring T; and Winkelmann W: Chondromyxoid fibroma of the sternum. Case report. Arch Orthop Trauma Surg ,1993.112: 255-6, 112255 1993 [PubMed]

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Fig. 1-C:: Photographs, made eight months postoperatively, showing the patient easily lifting a 10-kg weight (Fig. 1-C) and performing a push-up without difficulty (Fig. 1-D).

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Fig. 1-D:: Photographs, made eight months postoperatively, showing the patient easily lifting a 10-kg weight (Fig. 1-C) and performing a push-up without difficulty (Fig. 1-D).

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TABLE I: Preoperative and Postoperative Data

*Secondary malignancy after radiation therapy for Hodgkin disease.

Case	Gender, Age at Op. (yrs)	Size of Specimen (cm)	Histological Type	Location in Sternum	Margin According to Enneking System¹⁵	Durat. of Follow-up (mos)
1	M, 72	17 8 6	Chondrosarcoma, grade 1	Body	Wide	30
2	F, 62	13.5 5 7	Chondrosarcoma, grade 2	Manubrium	Wide	32
3	M, 37	16 8 3	Soft-tissue sarcoma, grade 3*	Body	Wide	24

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TABLE I: Preoperative and Postoperative Data

*Secondary malignancy after radiation therapy for Hodgkin disease.

Case	Gender, Age at Op. (yrs)	Size of Specimen (cm)	Histological Type	Location in Sternum	Margin According to Enneking System¹⁵	Durat. of Follow-up (mos)
1	M, 72	17 8 6	Chondrosarcoma, grade 1	Body	Wide	30
2	F, 62	13.5 5 7	Chondrosarcoma, grade 2	Manubrium	Wide	32
3	M, 37	16 8 3	Soft-tissue sarcoma, grade 3*	Body	Wide	24