How to Do It
Using “Rebar” to Stabilize Rigid Chest Wall Reconstruction Deanna M. Grubbs1
1 Department of Thoracic Oncology (Surgery), Moffitt Cancer Center,
Tampa, Florida, United States Thorac Cardiovasc Surg
Abstract
Keywords
► chest wall ► sternum ► surgery/incisions/ exposure/techniques ► wound closure ► chest wall reconstruction
After major chest wall resection, reconstruction of the bony defect with a rigid prosthesis is mandatory to protect the underlying thoracic organs, and to prevent flail chest physiology. Although many methods have been described for chest wall reconstruction, a commonly used technique employs a composite Marlex (polypropylene) mesh with methyl-methacrylate cement sandwiched between two layers of mesh (MMS), which is tailored to the defect size and shape. In building construction, steel “rebar” is used to strengthen and reinforce masonry structures. To avoid the initial residual motion of the rigid prosthesis used to reconstruct very large defects, particularly the sternum, we devised a simple technique of adding one or more Steinmann steel pins as “rebar” to strengthen and immediately stabilize the prosthesis to the surrounding ribs and sternum. For the very large defects, particularly over the heart and great vessels, titanium mesh may also be readily added into the sandwich construction for increased strength and to prevent late prosthetic fractures. Short- and long-term results of this inexpensive modification of the MMS reconstruction technique are excellent. This modified MMS tailor-made prosthesis is only one-third the cost of the recently popular prosthetic titanium systems, takes much less operative time to create and implant, and avoids the well-described complications of late titanium bar fracture and erosion/infection as well as loosening of screws and/or titanium bars.
Introduction Malignancies involving the chest wall requiring major resection of multiple ribs and/or the sternum leave a large bony defect. To protect underlying viscera and to prevent flail chest physiology, chest wall reconstruction demands a rigid prosthesis. Although many techniques have been described for chest wall reconstruction, 1,2 we prefer the McCormack, et al, technique3 using composite Marlex mesh with methyl-methacrylate cement sandwiched between two mesh layers (MMS). Sized to fit, the prosthesis is readily sutured to the bony margins. This highly-effective technique works well, but in larger defects, especially the sternum, residual prosthesis motion may occur for weeks until stabilized by fibrosis.
received October 14, 2014 accepted after revision November 17, 2014
Address for correspondence Lary A. Robinson, MD, Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, Florida 33612-9497, United States (e-mail: lary.robinson@moffitt.org).
Rebar, or reinforcing bar, is steel cast into masonry structures to strengthen concrete and has been used since the 19th century.4 We borrowed this technique to stabilize MMS reconstruction by casting steel Steinmann pins into the methyl-methacrylate cement with protruding ends inserted into bony marrow cavities.
Case Example A 53-year-old male obese deputy sheriff noticed a painful upper sternal mass. A chest CT scan showed a 6-cm diameter expansile mass involving the manubrium and sternal body extending from the clavicles inferiorly to the third ribs. Radical resection of this isolated, highly symptomatic mass was performed.
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1396933. ISSN 0171-6425.
Downloaded by: University of Florida. Copyrighted material.
Lary A. Robinson1
Rebar Stabilization
Robinson, Grubbs
Through an upper partial sternotomy skin incision, the tumor was resected, excising en bloc the two clavicular heads, the manubrium, and upper half of the sternal body, including the costal cartilages 1 to 3 bilaterally. Reconstruction was accomplished using an MMS-titanium prosthesis embedded with two Steinmann pins to stabilize the prosthesis to the clavicles and the remaining sternum. The patient recovered uneventfully and within 2 months resumed running 2 miles/ day. Surprisingly, the pathology showed a 9 cm 8 cm plasmacytoma with negative margins. Postoperative evaluation for multiple myeloma was negative. Three years later, the patient finally manifested multiple myeloma, underwent chemotherapy and eventually autologous stem cell transplant 7 years later. Currently, the patient is asymptomatic and works full-time 13 years postoperatively.
In the example, the medial borders of the pectoralis muscles were resected with the clavicular heads, manubrium, upper sternal body, and the costal cartilages of ribs 1 to 3. Before passing off the specimen, it was placed on a surgical towel and the border was traced with a marker. Polypropylene mesh of size 25 cm 36 cm (Bard, Cranston, Rhode Island, United States) was folded into two layers and cut to the size of the bony defect using the marked towel as a template. Methylmethacrylate cement (DePuy Orthopedics, Warsaw, Indiana, United States) was placed on one layer of the mesh, extending within 1 cm of the edge. Titanium micromesh (Codman, Raynham, Massachusetts, United States) was cut with scissors and covered the cement. Two 2.8 mm (7/64″) diameter Steinmann pins (Teleflex Medical, Research Triangle, North Carolina, United States) were also placed into the cement, extending 5 cm outside the mesh in each direction, with the upper pin to be guided into the marrow cavity of each clavicle and the U-shaped lower pin to be inserted into the remaining sternum. Finally, more cement was placed and the top layer of polypropylene mesh was pressed into the cement. The entire 12 cm 13 cm prosthetic “sandwich” was molded in a slightly convex shape to conform to the sternum (►Fig. 1). 0-Prolene sutures (Ethicon, Somerville, New Jersey, United States) were placed through the rib edges (holes made with a hand drill) and #2 steel wire (Ethicon) was placed through holes drilled in the clavicles and sternum. The hardened prosthesis, when cool, was then slipped into place with the two ends of the upper pin inserted into the clavicles and the ends of the lower pin directed into the sternum. The polypropylene and the steel wires were then sutured to the edge of the mesh. 2–0 Prolene sutures were placed between the intercostal muscles and the mesh. The sternal heads of the sternocleidomastoid were sutured to the mesh with 0-Vicryl sutures. ►Fig. 2 shows the prosthesis in place prior to wound closure. Both pectoralis muscles were closed primarily over the prosthesis, followed by primary closure of subcutaneous tissue and skin. ►Fig. 3 is a chest radiograph taken at hospital discharge and ►Fig. 4 shows the prosthesis in place in a chest CT scan 8 years postoperatively. Thoracic and Cardiovascular Surgeon
Fig. 1 MMS/titanium micromesh/Steinmann pin prosthesis ready for implant.
Fig. 2 Prosthesis implanted in chest wall defect just prior to wound closure.
Discussion For larger defects (3 ribs) or sternal reconstruction, residual respiratory motion of the MMS prosthesis may occur with pain until stabilized by fibrosis. To provide immediate stability, strengthen the construction, and avoid the tendency of the prosthesis to bow inwardly from negative intrathoracic pressure, we casted Steinmann pins into the prosthesis with ends extending outside for insertion into the ribs/sternum. We include titanium micromesh in the MMS prostheses covering large chest wall defects, especially when protecting the heart/ great vessels, which adds strength and prevents late
Downloaded by: University of Florida. Copyrighted material.
Surgical Technique
Robinson, Grubbs
Fig. 3 PA chest radiograph at hospital discharge. The superior pin extends into each clavicle (superior arrows); the inferior U-shaped pin extends into the sternum (inferior arrows).
Fig. 4 Axial chest computed tomogram showing MMS prosthesis in place (arrows) 8 years postoperatively.
fracturing of the MMS. The usual operative time for fabrication and implantation of the MMS/rebar prosthesis (after specimen removal) is 25 to 30 minutes, and skin wound closure then follows immediately. Current hospital cost for materials to create an MMS prosthesis is ($217), plus titanium micromesh ($883) with Steinmann pins ($36), totaling $1,136. In contrast, the current hospital cost of the prosthetic titanium sternal osteosynthesis system including screws ($2,700) and a polytetrafluoroethylene PTFE graft ($1,295) or an antibiotic-impregnated PTFE Dualmesh graft ($2,858 retail) bridging the defect for reconstruction of the described sternal/clavicular/rib defect totals $3,995 or more, and the reconstruction generally takes far longer than the average 30 minutes required for the MMS– rebar prosthetic repair. In addition, the MMS–rebar repair
avoids the well-described complications of late titanium bar fracture and erosion/infection as well as loosening of screws and/or bars seen with prosthetic titanium systems that mandates more surgery.1,2 Interestingly, the forerunner of the metal osteosynthesis system was described in 2001 where the bony defect was covered with a flexible mesh or patch, and a metal bar (Grob-Stab) was treaded through the flexible mesh in the center of the defect and was attached to the ribs with steel Parham bands followed by muscle flap closure.5 The authors then explain that the metal bar was a “temporary aid” and was generally removed 2 to 3 months later with another surgical procedure under general anesthesia, a distinct disadvantage that often plagues the osteosynthesis systems as well. In contrast, the MMS/rebar prosthesis is molded in one piece that fits flush with the chest wall, does not require a
Table 1 Patients with MMS “Rebar” chest wall reconstruction of very large surgical defects Patient no.
Age/sex
Year of surgery
Tumor type
Resection
Wound closure
Early (< 90 d) wound/prosthesis complications
Late (> 90 d) wound/prosthesis complications
1 (case example)
53/M
2001
Plasmacytoma
Sternum, clavicles, ribs 1–3
Primary
None
None
2
74/F
2002
Localized mesothelioma
Ribs 6–8, lung
Primary
None
None
3
54/F
2002
Sarcoma, postradiation
Ribs 3–5, lung
Latissimus dorsi flap
None
None
4
21/F
2007
Osteosarcoma
Ribs 5–8
Primary
None
None
5
63/F
2009
Papillary thyroid carcinoma
Sternum, clavicles, ribs 1–2
Primary
None
None
6
32/F
2010
Leiomyosarcoma
Ribs 5–7, lung
Primary
None
None
7
71/M
2012
Metastatic renal cell carcinoma
Ribs 4–6, lung
Primary
None
None
Thoracic and Cardiovascular Surgeon
Downloaded by: University of Florida. Copyrighted material.
Rebar Stabilization
Rebar Stabilization
Robinson, Grubbs
muscle flap coverage (unless overlying subcutaneous tissue and skin are also resected with the tumor—an uncommon event), and remains in place lifelong. Since 1994, the author has successfully used the standard MMS chest wall reconstruction in 77 patients without early or late prosthesis dislodgement, fracture, chronic pain, or perceived (or real) respiratory impairment or chest wall stiffness. Titanium micromesh and Steinmann pin “rebar” were successfully added to seven of these later cases with very large surgical chest defects for greater stability and tensile strength of the prosthesis (►Table 1). Thoracic surgeons performing chest wall resections are encouraged to consider adopting this simple, inexpensive modification to their reconstruction technique that is applicable to any area of the thorax.
References 1 Thomas PA, Brouchet L. Prosthetic reconstruction of the chest wall.
Thorac Surg Clin 2010;20(4):551–558 2 Berthet JP, Canaud L, D’Annoville T, Alric P, Marty-Ane CH. Titani-
um plates and Dualmesh: a modern combination for reconstructing very large chest wall defects. Ann Thorac Surg 2011;91(6): 1709–1716 3 McCormack P, Bains MS, Beattie EJ Jr, Martini N. New trends in skeletal reconstruction after resection of chest wall tumors. Ann Thorac Surg 1981;31(1):45–52 4 Mörsch E. Concrete-Steel Construction. 1st ed. New York: The Engineering News Publishing Co.; 1910:204–209 5 Lampl L. Chest wall resection: a new and simple method for stabilization of extended defects. Eur J Cardiothorac Surg 2001; 20(4):669–673
Downloaded by: University of Florida. Copyrighted material.
Conflicts of Interest None.
Sources of Funding None.
Thoracic and Cardiovascular Surgeon
Using “Rebar” to Stabilize Rigid Chest Wall Reconstruction Deanna M. Grubbs1
1 Department of Thoracic Oncology (Surgery), Moffitt Cancer Center,
Tampa, Florida, United States Thorac Cardiovasc Surg
Abstract
Keywords
► chest wall ► sternum ► surgery/incisions/ exposure/techniques ► wound closure ► chest wall reconstruction
After major chest wall resection, reconstruction of the bony defect with a rigid prosthesis is mandatory to protect the underlying thoracic organs, and to prevent flail chest physiology. Although many methods have been described for chest wall reconstruction, a commonly used technique employs a composite Marlex (polypropylene) mesh with methyl-methacrylate cement sandwiched between two layers of mesh (MMS), which is tailored to the defect size and shape. In building construction, steel “rebar” is used to strengthen and reinforce masonry structures. To avoid the initial residual motion of the rigid prosthesis used to reconstruct very large defects, particularly the sternum, we devised a simple technique of adding one or more Steinmann steel pins as “rebar” to strengthen and immediately stabilize the prosthesis to the surrounding ribs and sternum. For the very large defects, particularly over the heart and great vessels, titanium mesh may also be readily added into the sandwich construction for increased strength and to prevent late prosthetic fractures. Short- and long-term results of this inexpensive modification of the MMS reconstruction technique are excellent. This modified MMS tailor-made prosthesis is only one-third the cost of the recently popular prosthetic titanium systems, takes much less operative time to create and implant, and avoids the well-described complications of late titanium bar fracture and erosion/infection as well as loosening of screws and/or titanium bars.
Introduction Malignancies involving the chest wall requiring major resection of multiple ribs and/or the sternum leave a large bony defect. To protect underlying viscera and to prevent flail chest physiology, chest wall reconstruction demands a rigid prosthesis. Although many techniques have been described for chest wall reconstruction, 1,2 we prefer the McCormack, et al, technique3 using composite Marlex mesh with methyl-methacrylate cement sandwiched between two mesh layers (MMS). Sized to fit, the prosthesis is readily sutured to the bony margins. This highly-effective technique works well, but in larger defects, especially the sternum, residual prosthesis motion may occur for weeks until stabilized by fibrosis.
received October 14, 2014 accepted after revision November 17, 2014
Address for correspondence Lary A. Robinson, MD, Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, Florida 33612-9497, United States (e-mail: lary.robinson@moffitt.org).
Rebar, or reinforcing bar, is steel cast into masonry structures to strengthen concrete and has been used since the 19th century.4 We borrowed this technique to stabilize MMS reconstruction by casting steel Steinmann pins into the methyl-methacrylate cement with protruding ends inserted into bony marrow cavities.
Case Example A 53-year-old male obese deputy sheriff noticed a painful upper sternal mass. A chest CT scan showed a 6-cm diameter expansile mass involving the manubrium and sternal body extending from the clavicles inferiorly to the third ribs. Radical resection of this isolated, highly symptomatic mass was performed.
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1396933. ISSN 0171-6425.
Downloaded by: University of Florida. Copyrighted material.
Lary A. Robinson1
Rebar Stabilization
Robinson, Grubbs
Through an upper partial sternotomy skin incision, the tumor was resected, excising en bloc the two clavicular heads, the manubrium, and upper half of the sternal body, including the costal cartilages 1 to 3 bilaterally. Reconstruction was accomplished using an MMS-titanium prosthesis embedded with two Steinmann pins to stabilize the prosthesis to the clavicles and the remaining sternum. The patient recovered uneventfully and within 2 months resumed running 2 miles/ day. Surprisingly, the pathology showed a 9 cm 8 cm plasmacytoma with negative margins. Postoperative evaluation for multiple myeloma was negative. Three years later, the patient finally manifested multiple myeloma, underwent chemotherapy and eventually autologous stem cell transplant 7 years later. Currently, the patient is asymptomatic and works full-time 13 years postoperatively.
In the example, the medial borders of the pectoralis muscles were resected with the clavicular heads, manubrium, upper sternal body, and the costal cartilages of ribs 1 to 3. Before passing off the specimen, it was placed on a surgical towel and the border was traced with a marker. Polypropylene mesh of size 25 cm 36 cm (Bard, Cranston, Rhode Island, United States) was folded into two layers and cut to the size of the bony defect using the marked towel as a template. Methylmethacrylate cement (DePuy Orthopedics, Warsaw, Indiana, United States) was placed on one layer of the mesh, extending within 1 cm of the edge. Titanium micromesh (Codman, Raynham, Massachusetts, United States) was cut with scissors and covered the cement. Two 2.8 mm (7/64″) diameter Steinmann pins (Teleflex Medical, Research Triangle, North Carolina, United States) were also placed into the cement, extending 5 cm outside the mesh in each direction, with the upper pin to be guided into the marrow cavity of each clavicle and the U-shaped lower pin to be inserted into the remaining sternum. Finally, more cement was placed and the top layer of polypropylene mesh was pressed into the cement. The entire 12 cm 13 cm prosthetic “sandwich” was molded in a slightly convex shape to conform to the sternum (►Fig. 1). 0-Prolene sutures (Ethicon, Somerville, New Jersey, United States) were placed through the rib edges (holes made with a hand drill) and #2 steel wire (Ethicon) was placed through holes drilled in the clavicles and sternum. The hardened prosthesis, when cool, was then slipped into place with the two ends of the upper pin inserted into the clavicles and the ends of the lower pin directed into the sternum. The polypropylene and the steel wires were then sutured to the edge of the mesh. 2–0 Prolene sutures were placed between the intercostal muscles and the mesh. The sternal heads of the sternocleidomastoid were sutured to the mesh with 0-Vicryl sutures. ►Fig. 2 shows the prosthesis in place prior to wound closure. Both pectoralis muscles were closed primarily over the prosthesis, followed by primary closure of subcutaneous tissue and skin. ►Fig. 3 is a chest radiograph taken at hospital discharge and ►Fig. 4 shows the prosthesis in place in a chest CT scan 8 years postoperatively. Thoracic and Cardiovascular Surgeon
Fig. 1 MMS/titanium micromesh/Steinmann pin prosthesis ready for implant.
Fig. 2 Prosthesis implanted in chest wall defect just prior to wound closure.
Discussion For larger defects (3 ribs) or sternal reconstruction, residual respiratory motion of the MMS prosthesis may occur with pain until stabilized by fibrosis. To provide immediate stability, strengthen the construction, and avoid the tendency of the prosthesis to bow inwardly from negative intrathoracic pressure, we casted Steinmann pins into the prosthesis with ends extending outside for insertion into the ribs/sternum. We include titanium micromesh in the MMS prostheses covering large chest wall defects, especially when protecting the heart/ great vessels, which adds strength and prevents late
Downloaded by: University of Florida. Copyrighted material.
Surgical Technique
Robinson, Grubbs
Fig. 3 PA chest radiograph at hospital discharge. The superior pin extends into each clavicle (superior arrows); the inferior U-shaped pin extends into the sternum (inferior arrows).
Fig. 4 Axial chest computed tomogram showing MMS prosthesis in place (arrows) 8 years postoperatively.
fracturing of the MMS. The usual operative time for fabrication and implantation of the MMS/rebar prosthesis (after specimen removal) is 25 to 30 minutes, and skin wound closure then follows immediately. Current hospital cost for materials to create an MMS prosthesis is ($217), plus titanium micromesh ($883) with Steinmann pins ($36), totaling $1,136. In contrast, the current hospital cost of the prosthetic titanium sternal osteosynthesis system including screws ($2,700) and a polytetrafluoroethylene PTFE graft ($1,295) or an antibiotic-impregnated PTFE Dualmesh graft ($2,858 retail) bridging the defect for reconstruction of the described sternal/clavicular/rib defect totals $3,995 or more, and the reconstruction generally takes far longer than the average 30 minutes required for the MMS– rebar prosthetic repair. In addition, the MMS–rebar repair
avoids the well-described complications of late titanium bar fracture and erosion/infection as well as loosening of screws and/or bars seen with prosthetic titanium systems that mandates more surgery.1,2 Interestingly, the forerunner of the metal osteosynthesis system was described in 2001 where the bony defect was covered with a flexible mesh or patch, and a metal bar (Grob-Stab) was treaded through the flexible mesh in the center of the defect and was attached to the ribs with steel Parham bands followed by muscle flap closure.5 The authors then explain that the metal bar was a “temporary aid” and was generally removed 2 to 3 months later with another surgical procedure under general anesthesia, a distinct disadvantage that often plagues the osteosynthesis systems as well. In contrast, the MMS/rebar prosthesis is molded in one piece that fits flush with the chest wall, does not require a
Table 1 Patients with MMS “Rebar” chest wall reconstruction of very large surgical defects Patient no.
Age/sex
Year of surgery
Tumor type
Resection
Wound closure
Early (< 90 d) wound/prosthesis complications
Late (> 90 d) wound/prosthesis complications
1 (case example)
53/M
2001
Plasmacytoma
Sternum, clavicles, ribs 1–3
Primary
None
None
2
74/F
2002
Localized mesothelioma
Ribs 6–8, lung
Primary
None
None
3
54/F
2002
Sarcoma, postradiation
Ribs 3–5, lung
Latissimus dorsi flap
None
None
4
21/F
2007
Osteosarcoma
Ribs 5–8
Primary
None
None
5
63/F
2009
Papillary thyroid carcinoma
Sternum, clavicles, ribs 1–2
Primary
None
None
6
32/F
2010
Leiomyosarcoma
Ribs 5–7, lung
Primary
None
None
7
71/M
2012
Metastatic renal cell carcinoma
Ribs 4–6, lung
Primary
None
None
Thoracic and Cardiovascular Surgeon
Downloaded by: University of Florida. Copyrighted material.
Rebar Stabilization
Rebar Stabilization
Robinson, Grubbs
muscle flap coverage (unless overlying subcutaneous tissue and skin are also resected with the tumor—an uncommon event), and remains in place lifelong. Since 1994, the author has successfully used the standard MMS chest wall reconstruction in 77 patients without early or late prosthesis dislodgement, fracture, chronic pain, or perceived (or real) respiratory impairment or chest wall stiffness. Titanium micromesh and Steinmann pin “rebar” were successfully added to seven of these later cases with very large surgical chest defects for greater stability and tensile strength of the prosthesis (►Table 1). Thoracic surgeons performing chest wall resections are encouraged to consider adopting this simple, inexpensive modification to their reconstruction technique that is applicable to any area of the thorax.
References 1 Thomas PA, Brouchet L. Prosthetic reconstruction of the chest wall.
Thorac Surg Clin 2010;20(4):551–558 2 Berthet JP, Canaud L, D’Annoville T, Alric P, Marty-Ane CH. Titani-
um plates and Dualmesh: a modern combination for reconstructing very large chest wall defects. Ann Thorac Surg 2011;91(6): 1709–1716 3 McCormack P, Bains MS, Beattie EJ Jr, Martini N. New trends in skeletal reconstruction after resection of chest wall tumors. Ann Thorac Surg 1981;31(1):45–52 4 Mörsch E. Concrete-Steel Construction. 1st ed. New York: The Engineering News Publishing Co.; 1910:204–209 5 Lampl L. Chest wall resection: a new and simple method for stabilization of extended defects. Eur J Cardiothorac Surg 2001; 20(4):669–673
Downloaded by: University of Florida. Copyrighted material.
Conflicts of Interest None.
Sources of Funding None.
Thoracic and Cardiovascular Surgeon
