|Year : 2018 | Volume
| Issue : 2 | Page : 122-127
Chest wall reconstruction for traumatic chest wall lesions
Mohammed K Abdelnaby, Hany M Elrakhawy, Mohammed M Saffan, Ataa E.A. Abdallah
Department of Cardiothoracic Surgery, Faculty of Medicine, Benha University, Benha, Egypt
|Date of Submission||24-Dec-2016|
|Date of Acceptance||06-Feb-2017|
|Date of Web Publication||17-Aug-2018|
Dr. Ataa E.A. Abdallah
7 Masged Eltoba Street, Qusena, Elmenoufia, 32511
Source of Support: None, Conflict of Interest: None
Background The study was conducted to project the different available surgical modalities of chest wall reconstruction for different traumatic chest wall lesions.
Patients and methods Sixty patients were divided into two equal groups of 30 patients each. In the first group, skeletal tissue reconstruction was performed using plates and screws in 15 patients. In the second group, soft tissue reconstruction was performed using latissimus dorsi flap in 15 patients and using pectoralis major flap in the other 15 patients. The mandibular plate was the type used in fixation with three interlocking screws on each side of fracture. The prolene mesh was sutured to margins of skeletal defects with interrupted prolene sutures and then covered with muscle flap. The latissimus dorsi flap was used to cover lateral and anterior soft tissue defects. In addition, pectoralis major flap was used to cover superioanterior and upper lateral soft tissue defects. Each patient was assessed for primary outcomes such as ICU admission, mechanical ventilation, and hospital stay and secondary outcomes such as deformity, redo surgery, and death.
Results The need for mechanical ventilation, ICU admission, seroma formation, redo surgery, hospital stay, and deformity are more decreased in the plates and screws subgroup than in prolene mesh reconstruction, but no difference was found in chest infection, wound infection, and death between the two subgroups. However, flap hematoma, seroma formation, and residual deformity are more decreased in pectoralis major flap than in latissimus dorsi flap.
Conclusion Fixation of fractures with metal plates and screws decrease morbidity. Most skeletal chest wall defects can be reconstructed with prolene mesh. The latissimus dorsi and pectoralis major flaps are the most versatile and reliable flaps used in reconstruction today.
Keywords: chest wall, reconstruction, trauma
|How to cite this article:|
Abdelnaby MK, Elrakhawy HM, Saffan MM, Abdallah AE. Chest wall reconstruction for traumatic chest wall lesions. Benha Med J 2018;35:122-7
|How to cite this URL:|
Abdelnaby MK, Elrakhawy HM, Saffan MM, Abdallah AE. Chest wall reconstruction for traumatic chest wall lesions. Benha Med J [serial online] 2018 [cited 2018 Dec 13];35:122-7. Available from: http://www.bmfj.eg.net/text.asp?2018/35/2/122/239201
| Introduction|| |
Chest wall trauma is a significant cause of morbidity and mortality in both adults and children. Chest wall injuries are divided into blunt traumas and penetrating chest wounds. The most common cause of blunt trauma is the road traffic accidents, which represent 70% . Skeletal chest wall reconstruction not only restores skeletal rigidity but also protects the vital organs and vascular structures contained within the thorax. Furthermore, it prevents herniation of thoracic organs . Soft tissue reconstruction includes several options, from local and regional muscle or myocutaneous flaps to more advanced reconstructive techniques such as microsurgical free tissue transfer. The excellent vascularity of these flaps provides the most reliable means of reconstructing complex chest wall defects .
Early reduction and fixation of multiple fractured ribs and flail chest with plates and screws restore the chest wall integrity and thus decrease the permanent damaging sequelae such as severe displacement during healing. This leads to decreased deformity, volume loss, choronic pain, and atelectasis, which lead to ventilatory insufficiency. The long-term problems of these patients include subjective chest tightness, thoracic cage pain, and dyspnea .
Chest wall reconstruction in skeletal defects is safe and effective in immediate setting as most defects can be reconstructed with synthetic mesh such as prolene mesh and then covered with latissimus dorsi flap . The advantages of prolene mesh are as follows: it easy to handle, has long-term tolerability without foreign body reactions, provides semirigid support, and no significant clinical evidence of paradoxical movement .
Latissimus dorsi muscle represents the flap of choice for anterior and lateral chest wall defects because of its position, size, bulk, and the arc of rotation. However, its usage is sometimes limited because it is transsected by previous thoracotomy. It has a thick vascular pedicle and can be elevated and rotated on a generous arc to reach the ipsilateral chest and also the midline .
The pectoralis major muscle flap is the most commonly used muscle flap for the reconstruction of sternal, anterosuperior chest, intrathoracic, and neck wounds .
| Patients and methods|| |
After obtaining approval from the Benha university Hospital Ethics Committee and written informed consent from patients, we studied 60 patients with chest wall trauma scheduled for chest wall reconstruction. Patients were excluded if there was a cerebrovascular stroke, severe abdominal injury, and associated coma due to trauma. BMI of cases ranged from 16.14 to 40.35. Patients were allocated to two equal groups: the first group (n=30) included patients who underwent skeletal tissue reconstruction using plates with screws in 15 patients and prolene mesh with coverage latissimus dorsi flap in another 15 patients for reconstruction of skeletal fractures and tissue defects, and the second group (n=30) included patients who underwent soft tissue reconstruction in the form of latissimus dorsi flap in 15 patients and pectoralis major flap in another 15 patients for the reconstruction of soft tissue defects.
The fractured ribs were fixed with metal mandibular plate and at least three interlocking screws on each side of the fracture were used to fix it. Prolene mesh was used to close large skeletal defect. It was sutured circumferentially with slight tension to the edges of the skeletal defect. This was carried out using interrupted 2/0 polypropylene sutures and then the mesh was covered with muscle flap.
Latissimus dorsi flap is easily harvested through a standard posterolateral thoracotomy incision. The latissimus is then divided posteriorly and inferiorly until it is on a pedicle from the thoracodorsal bundle and the humerus.
The pectoralis major is dependent on the thoracoacromial bundle, with the arterial supply arising midclavicle from the subclavian artery. When harvested as an isolated flap, the infraclavicular incision is preferred.
The primary outcome in this study was ICU admission, mechanical ventilation, seroma formation, wound infection, hospital duration, and death. Secondary outcome measures were nonhealing, redo surgery, and residual deformity. Statistical analyses were performed using a standard statistical program (SPSS, version 16) (SPSS Inc., Chicago, Illinois, USA). Quantitative data were presented as mean±SD. Qualitative data were presented as numbers and %. Quantitative data were analyzed using the unpaired Student’s t-test, and quantitative data in the same group were analyzed using the repeated measure analysis of variance test. However, qualitative data were analyzed using the χ2-test. A P value less than 0.05 was considered statistically significant and P value less than 0.01 was considered statistically highly significant ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
|Figure 1 Distribution of male and female patients between the two groups of chest wall reconstruction.|
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|Figure 2 Distribution of mortality cases between the two groups of chest wall reconstruction.|
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|Figure 3 Incidence of deformity among patients who underwent reconstruction with plates and screws and those who underwent reconstruction with prolene mesh.|
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|Figure 4 Incidence of deformity among patients who underwent reconstruction with latissimus dorsi muscle flap and those who underwent reconstruction with pectoralis major muscle flap.|
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| Results|| |
Sixty patients were enrolled in the study. Overall, 30 patients underwent skeletal chest wall reconstruction using plates and screws in fracture of the ribs and flail chest and prolene mesh by covering latissimus dorsi flap in skeletal chest wall defects. The other 30 patients underwent soft tissue reconstruction with latissimus dorsi flap and pectoralis major flap in cases with soft tissue defects. Demographic characteristics showed no difference as regards age, BMI and ratio of males to females, as in [Table 1].
|Table 1 Distribution of the studied group as regards demographic data and anthropometric measurements|
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The age of cases ranged between 20 and 67 years. In all, 48 (80%) patients were male and 12 (20%) patients were female. The weight of cases ranged from 50 to 98 kg (SD=13.89). The height ranged from 1.5 to 1.85 m (mean: 1.69). BMI of cases ranged from 16.14 to 40.35.
The negative wound suction therapy was used in five patients in group 1 and in six patients in group 2. The wound infection occurred in six patients (same value) in two groups of chest wall reconstruction. The incidence of nonhealing of the wound occurred higher in group 1 (10 patients) compared with group 2 (five patients). Naked eye chest wall deformity was less in group 1 and occurred in six cases versus 13 cases in group 2. The incidence of redo surgery was higher in group 1 compared with group 2 (eight vs. five cases). Mortality was high in group 1 than in group 2 (six vs. two cases) ([Table 2]). Current study shows significant differences between the two groups as regards hospital stay with a decrease in stay in group 2.
|Table 2 Distribution of cases between group I and group II of chest wall reconstruction in patients with chest trauma as regards multiple variables|
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There was a statistically significant decrease in the incidence of residual deformity in cases that underwent treatment with plates and screws compared with cases that underwent treatment with prolene mesh (P≤0.05; [Table 3]). Moreover, there was a statistically significant decrease in the incidence of deformity in cases that underwent reconstruction with pectoralis major muscle flap compared with cases that underwent reconstruction with latissimus dorsi muscle flap (P≤0.05; [Table 4]).
|Table 3 Distribution of cases between the two subgroups of skeletal tissue reconstruction as regards residual deformity|
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|Table 4 Results of two subgroups of soft tissue reconstruction as regards residual deformity|
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There was a statistically significant decrease in the incidence of nonhealing in cases with plates and screws than that in cases with prolene mesh (P≤0.05). Moreover, there was a statistically significant decrease in the incidence of redo surgery in cases that underwent reconstruction with plates and screws compared with cases with prolene mesh (P≤0.05). However, as regards hospital stay, there was a statistically significant decrease in the period of hospital stay in cases treated with plates and screws lower than in cases treated with prolene mesh (P≤0.05).
No statistically significant difference was found between cases that underwent reconstruction with pectoralis major muscle flap and cases that underwent reconstruction with latissimus dorsi muscle flap as regards the incidence of nonhealing (P>0.05). Moreover, there was no statistical significance between cases that underwent reconstruction with pectoralis major muscle flap and cases that underwent treatment with latissimus dorsi muscle flap as regards the incidence of redo surgery (P>0.05). No statistically significant difference was found between cases with pectoralis major muscle flap and cases with latissimus dorsi muscle flap as regards the period of hospital stay (P>0.05).
| Discussion|| |
Reconstruction of chest wall defects represents a great challenge and requires cooperation between the cardiothoracic surgeon and plastic surgeons to achieve good outcome and reduce the incidence of complications .
Our study includes 60 patients divided in two groups. Each group included 30 patients. In the first group, skeletal chest wall reconstruction was performed using the plating system with screws in fracture ribs and prolene mesh in skeletal defect. In the second group, soft tissue reconstruction was performed using latissimus dorsi and pectoralis major flaps in soft tissue defects.
As regards healing and redo surgery, there was a statistically significant difference between the two subgroups of skeletal reconstruction (P=0.02 and 0.01, respectively) with a decreased incidence of healing and in consequence an increased incidence of redo surgery in the prolene mesh subgroup.
Healing and redo surgery results are in agreement with the results of Borrely and colleagues, who conducted a retrospective review on 127 patients in 1985. The fractures were fixed with judet staples.
The above results can be attributed to increased wound infection and associated comorbidities such as associated diseases and traumas .
With plating system for fixation of fracture of the ribs, the hospital stay was decreased. However, the stay is increased with prolene mesh (P=0.01). That result is in agreement with the findings of Slater and colleagues, who conducted a retrospective review on 64 patients in 2001. Slater also demonstrated decreased mortality in the fracture rib group.
Slater et al. (2001) found that by decrease pain with early ampulation, decrease paradoxical movement and cut the vicious circles of fracture ribs which leads to deterioration in plates and screws subgroup. However, in prolene reconstruction, there was an increased incidence of seroma, wound infection, and decreased healing .
As regards deformity in [Table 3], which showed the outcome of subgroups of skeletal reconstruction, there was a statistically significant P value of 0.006 with decreased deformity in plating system subgroups than in prolene mesh subgroup.
In our study, deformity is defined as naked eye deformity not radiological deformity, as computed tomography of the chest postoperatively reveals that the hemithoracic space is significantly smaller on the traumatized operated side. It is radiological deformity not naked eye deformity.
The deformity results in [Table 3] are in agreement with those of Actis Dato and colleagues., who conducted a prospective randomized study on 40 patients in 1999 and fractures were fixed with kirschner wires.
Deformity is increased in patients reconstructed with prolene mesh due to the absence of skeletal support in chest wall defects and increased wound infection and redo surgery in this subgroup .
As regards healing and redo surgery between muscle flap subgroups. No statistically significant difference was found between latissimus and pectoralis muscle flaps in nonhealing and the redo surgery (P=0.62 for both).
The above results are in agreement with the results of Mansour and colleagues, who revealed the experience of chest wall reconstruction for 25 years in 2002. Mansour stated that the redo surgery is due to nonhealing. The nonhealing includes seroma formation, wound infection, flap hematoma, and flap loss .
As regards soft tissue reconstruction using pectoralis and latissimus muscle flaps, no statistically significant difference between the two subgroups in duration of hospital stay (P=0.09), with long hospital stay time in the two types of flaps.
Hospital stay results are in agreement with Tan and colleagues, who conducted a study for analysis of 31 cases in 2003. He stated that long hospital stay was due to the long time of preoperative preparation, vacuum-assisted wound closure (VAC) use, wound care, bad general conditions due to associated traumas and diseases, and redo surgery .
As regards deformity occurring in the two muscle flap subgroups ([Table 4]), there was a statistically significant P value of 0.009 with decreased deformity in the pectoralis major flap subgroup.
The above result is in agreement with the findings of Pairoleo and Arnold, who conducted a study on 205 patients with thoracic wall defects in 1986. They attributed decreased deformity in patients who underwent pectoralis flap in chest trauma to decreased seroma formation, decreased hematoma, decreased wound infection, and decreased flap loss, which leads to decreased redo surgery .
| Conclusion|| |
Finally, fixation of fractures with metal plates and screws decreases morbidity. Most skeletal chest wall defects can be reconstructed with prolene mesh. The latissimus dorsi and pectoralis major flaps are the most versatile and reliable flaps used in reconstruction today.
First and foremost, the author thanks ALLAH, the most merciful, for blessing him in this work until it had reached its end.
The author would like to express his sincere appreciation and deep gratitude to Prof. Dr. Mohammed Khairy Abdelnaby, Professor of Cardiothoracic Surgery, Faculty of Medicine, Benha University, whose expertise, understanding, patience and added considerably to his experience and always be a source of knowledge to all of them.
No word can express the efforts done by Ass. Prof. Dr. Hany Mohammed Elrakhawy, Assistant Professor of Cardiothoracic Surgery, Faculty of Medicine, Benha University, for his close supervision, help, valuable guidance, kind advice and constant assistance throughout every step of this work.
He is greatly honored to express his appreciation to Ass. Prof Dr. Mohammed Mohammed Saffan, Assistant Professor of Cardiothoracic Surgery, Faculty of Medicine, Benha University, for his keen supervision, constructive comments, careful revision of this thesis as he really saved no effort in guiding him step by step throughout this study, sacrificing freely his precious time, too much thanks for him.
The author would also like to thank Dr. Basem Mofreh Aglan, Lecturer of Cardiothoracic Surgery, Faculty of Medicine, Benha University, for his continuous support and help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]