SURGICAL TECHNIQUE
European Journal of Cardio-Thoracic Surgery 43 (2013) 643–645
doi:10.1093/ejcts/ezs512 Advance Access publication 20 September 2012
Mesh–bone cement sandwich for sternal and sternoclavicular
joint reconstruction
Stéphane Collauda,*, Denis Pfofeb, Marco Decurtinsa and Hans Gelpkea
a
b
Department of Surgery, Winterthur Canton Hospital, Winterthur, Switzerland
Department of Pathology, Winterthur Canton Hospital, Winterthur, Switzerland
* Corresponding author. Department of Surgery, Kantonsspital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland. Tel: +41-52-2662402;
fax: +41-52-2662454; e-mail: [email protected] (S. Collaud).
Received 12 June 2012; received in revised form 27 July 2012; accepted 9 August 2012
Abstract
Resection of the manubrium including both sternoclavicular joints is occasionally performed in the case of sternal tumours.
Sternoclavicular joints are the only true joints connecting the axial skeleton to the upper extremity. Therefore, they play an important
role in shoulder function. However, data on their reconstruction are lacking. Here, we described the case of a sternal reconstruction including both sternoclavicular joints using a mesh–bone cement sandwich. The mechanical properties of the construct mimicked those
of the original sternoclavicular joints and could therefore restore shoulder strength allowing the patient to perform overhead work.
INTRODUCTION
A 45-year old male was referred to our outpatient with a
1-month history of painless swelling localized to the manubrium.
The computed tomography (CT) and the magnetic resonance
imaging of the chest revealed a 5.6 × 7.2 × 6.9 cm sternal mass
located to the manubrium (Fig. 1). The open sternal biopsy
could not differentiate between a benign chondral lesion and a
low-grade chondrosarcoma. A bone scintigraphy did not show
evidence of osseous metastasis.
The patient was brought to the operating room for tumour
resection. The pectoralis major muscles were dissected bilaterally
via an incision involving the skin together with the previous site
of biopsy and soft tissue overlying the mass. A full-thickness
resection of the manubrium was performed together with the
medial part of both clavicles and bilateral costochondral arches
(first and second). For reconstruction, a 20 cm × 15 cm collagencoated polypropylene mesh (Parietene™ Composite) was laid
directly on the lungs, posterior to the rib and sternum. The collagen coated on the visceral side of the polypropylene mesh was
thought to prevent adhesion formation of the lung with bony
structures. The mesh was transosseously anchored to the ribs
and sternum with non-absorbable sutures (Fig. 2A). Two additional 15 cm × 15 cm meshes (Ultrapro™) were laid on the ribs
and sternum, posterior to the pectoralis major muscles. Their
cephalic parts were wrapped dorsally or ventrally around the clavicles. Non-absorbable transosseous sutures were used to
anchor both Ultrapro™ meshes to the ribs, sternum and clavicles.
Finally, bone cement was spread between the Parietene™
Composite and Ultrapro™ meshes (Fig. 2B). Figure 2C shows
an intraoperative view of the mesh–bone cement sandwich in
situ. At the end of the procedure, the patient was successfully
extubated in the operating room. The construct was stable and
no paradoxical breathing was noted.
Histopathological tumour examination revealed a chondrosarcoma pT2 cM0, G2 (IIB), R0 according to the Enneking/MSTS
staging system [1]. The postoperative period was uneventful, and
the patient was discharged on postoperative day 12. The
3-month follow-up was marked by a good wound healing
without the sign of prosthesis infection. The 9-month follow-up
showed a full range of motion for both shoulders. Shoulder stability and strength was ensured allowing overhead work like drilling the ceiling. The patient reported overall pain as ‘mild’ and
could swim at 15 months postoperatively. No local or pulmonary
recurrence was revealed during the last follow-up on the chest
CT and bone scintigraphy.
COMMENT
Chondrosarcoma is the most frequent primary malignant chest
wall tumour with an incidence of <0.5 per million and year [2]. It
involves the sternum and the ribs in about 20 and 80%, respectively. There is no effective chemotherapy, and chondrosarcomas
are relatively radioinsensitive. Hence, surgical resection remains
the only effective treatment [3].
Chondrosarcoma tends to be large tumours at diagnosis, and
extended resections are frequently performed to provide sufficient resection margins [3]. This implies most of the timechallenging chest wall reconstructions. Usually, muscle/omentum
alone or musculocutaneous flaps are used for a soft tissue
reconstruction of the chest wall [4]. The reconstruction of the
skeletal chest wall can be obtained with different prosthetic
materials (Vicryl®, Marlex®, Gore-Tex®) with or without methyl
© The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
SURGICAL TECHNIQUE
Keywords: Chest wall
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S. Collaud et al. / European Journal of Cardio-Thoracic Surgery
Figure 1: A sagittal CT scan image showing the chondrosarcoma involving the
manubrium.
methacrylate, autogenous tissues (ribs and bone grafts) or
mouldable titanium bars and rib clips (Strasbourg Thoracic
Osteosyntheses System, STRATOS™) [4]. More recently, a cryopreserved sternochondral allograft was successfully transplanted [5].
Here, we describe an original case of sternal reconstruction including both sternoclavicular joints using the mesh–bone
cement sandwich. This semi-rigid construct mimicked the biomechanical properties of the sternoclavicular joints, aiming for
the restoration of shoulder stability and strength, allowing overhead work.
The sternoclavicular joint is the only true joint connecting
the axial skeleton to the upper extremity. The sternoclavicular
joint is inherently unstable, because less than half of the
medial clavicle articulates with the upper angle of the
sternum. The stability of the joint relies on the strong ligamentous support due to the anterior and posterior capsular
ligaments, the costoclavicular ligament and the interclavicular
ligament. Its degree of motion comprises 30–35° upward
elevation, 35° translation in the anterior to posterior plane.
The motion of the sternoclavicular joint occurs mostly in the
first 90° of arm elevation, with a ratio of 4° of the sternoclavicular motion for 10° of arm elevation. Almost no sternoclavicular motion occurs at high degrees of arm elevation [6]. Due
to its high degree of motion, attempted fixation or fusion has
often led to hardware loosening and migration, with sometimes fatal results [7]. Thus, the sternoclavicular joint reconstruction has to be a semi-rigid construct mimicking the
ligamentous stability. We chose a macroporous partially absorbable lightweight mesh (Ultrapro™), which offered an excellent strength and some longitudinal elasticity. Both Ultrapro™
meshes were anchored to the sternum (caudally), to the ribs
(laterally) and wrapped around the clavicles (cranially) in a way
that the original position of both clavicles was restored. Thus,
the original upward elevation of the sterno-clavicular joint was
Figure 2: (A) Schematic intraoperative view depicting the extension of the resection and the location of the Parietene™ Composite mesh (in green). The
non-visible part of the mesh is depicted in light green. (B) Parasagittal schematic view highlighting the relation of the three meshes to the bony structures. The Parietene™ Composite (in green) was laid on the lungs, posterior
to the rib and sternum. The two Ultrapro™ meshes (in blue) were laid on the
ribs and sternum, posterior to the pectoralis major muscles. The deepest one
(continuous blue line) and the most superficial one (dashed blue line) were
wrapped dorsally and ventrally to the clavicles, respectively. Bone cement (in
light grey) was sandwiched between the Parietene™ Composite (in green)
and Ultrapro™ (in blue) meshes. (C) Intraoperative view showing the most
superficial part of the mesh–bone cement sandwich construct. The bone
cement (in white) is apparent under both Ultrapro™ meshes (in white-blue).
obtained given the longitudinal elastic properties of both
Ultrapro™ meshes. Regarding the sternoclavicular motion in
the antero-posterior plane, it was limited by the range of
motion of the meshes around their fixation point on the first
ribs. Then, this construct mimicked the ligamentous biomechanical properties of the original sternoclavicular joints and
could therefore restore shoulder strength allowing the patient
to perform overhead work.
Conflict of interest: none declared.
S. Collaud et al. / European Journal of Cardio-Thoracic Surgery
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SURGICAL TECHNIQUE
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