Chondrotomy and sternotomy combined with the Nuss procedure for severe asymmetric pectus excavatum: how to do it.

The correction of severe asymmetric pectus excavatum is still challenging, especially for adults with a rigid thorax. For the repair of asymmetric cases, we introduce our surgical techniques added to the Nuss procedure. Chondrotomy of the depressed and deformed costal cartilage to elevate the depressed side was performed in a 42-year-old female patient. The depressed chest wall was directly elevated using pectus bars. Her sternal rotation angle improved from 27° to 15° after bar removal. In a 26-year-old male patient, oblique sternotomy and chondrotomy were performed. The sternal rotation angle improved from 26° to 9° postoperatively. These techniques were effective for correcting severe asymmetric pectus excavatum in adults.

Ultrasonographic evaluation of costal cartilage for microtia reconstruction surgery.

PURPOSE: Autogenous costal cartilage grafts have gained the golden standard method in microtia reconstruction. Right now, there was no useful method to assess the quality of costal cartilage before microtia reconstruction surgery. The purpose of this study was to evaluate the role of ultrasonography in assessing costal cartilage in patients who were ready to do microtia reconstruction surgery. METHODS: A prospective controlled study was conducted to collect 65 patients who underwent microtia reconstruction and underwent ultrasonography of costal cartilage before operation. The results of costal cartilage calcification and honeycombed phenomenon measured by ultrasonography were compared with those during operation. The age-specific patterns in calcification and honeycombed phenomenon were explored. RESULTS: According to the results of ultrasonography, the positive rate of calcification was 10.9% in patients under 18 years old, while 80% in patients over 18 years old. The positive rate of honeycombed phenomenon was 2.8% in patients under 12 years old, 42.9% in patients between 12 and 18 years old, and 25% in patients over 18 years old. Compared with intraoperative results, the accuracy rate of ultrasonography for calcification was 100%. The accuracy rate for honeycombed phenomenon was 83.3%. CONCLUSION: Ultrasonography has high accuracy rate in assessing the calcification and honeycombed phenomenon of the costal cartilage, which was of vital importance for microtia reconstruction. The quality of costal cartilage changed with the age.

Experimental study on maintaining the curvature of transplanted cartilage: Influence of the number of cartilage struts.

BACKGROUND: When auriculoplasty is performed for microtia, wire often becomes exposed during the long postoperative period. We have investigated other materials for fixing cartilage. We previously reported that absorbable sutures are more appropriate than wire. The present animal experiments investigated the reasons why fixation of transplanted cartilage is maintained when using absorbable sutures. METHODS: The costal cartilages of Sprague-Dawley rats were harvested, and three cartilage transplant models were prepared. After bending a costal cartilage into a U-shape, it was fixed by using only absorbable sutures as the control or was fixed by suturing one or two cross struts of cartilage to the U-shaped graft. Then the cartilages were subcutaneously transplanted into the backs of the rats. They were removed 8 weeks later, and the return rate of the bent cartilages was assessed. RESULTS: The return rate was 74.0%, in the suture-only group (control), 27.9% in the one-strut group, and 8.3% in the two-strut group. When the sites of contact between the U-shaped graft and the cartilage struts were observed by light microscopy, adhesion of the two cartilages by fibrous connective tissue was observed. CONCLUSION: U-shaped cartilage grafts demonstrated a smaller return rate when there was a larger contact area with the cartilage struts. Each strut was fixed by fibrous connective tissue at the contact site, thereby maintaining the shape of the graft. Thus, when creating a cartilage framework, it is important to fix the bent cartilage to the cartilage struts with a sufficiently large contact area.

Against the Overgrowth Hypothesis: Shorter Costal Cartilage Lengths in Pectus Excavatum.

BACKGROUND: Pectus excavatum is a common chest wall deformity with no known cause. A common hypothesis is that in patients with pectus excavatum, there is an overgrowth of costal cartilage relative to healthy individuals. MATERIALS AND METHODS: We obtained radiological curvilinear three-dimensional measurements of the fourth to eighth costal cartilage and associated ribs in 16 patients with pectus excavatum and 16 age- and gender-matched controls between the ages of 6 and 32 y. An analysis of variance was used to compare bone length, cartilage length, and their ratios between patients and controls. RESULTS: Relative to bone length, patients with pectus excavatum overall had shorter costal cartilage lengths (P < 0.001), especially on the left side (P < 0.05). We were unable to localize this observation to specific ribs during post hoc analysis. CONCLUSIONS: This is the first study to empirically test the overgrowth hypothesis of pectus excavatum for ribs 4 through 8. Although we and others have found no evidence to support this hypothesis, we surprisingly found the alternate hypothesis to be true: patients with pectus excavatum tend to have shorter costal cartilages. Future studies should expand on these results with larger sample sizes and consider volumetric measurements longitudinally during thoracic development.

Abnormal response of costal chondrocytes to acidosis in patients with chest wall deformity.

Costal cartilage is much understudied compared to the load bearing cartilages. Abnormally grown costal cartilages are associated with the inherited chest wall deformities pectus excavatum and pectus carinatum resulting in sunken or pigeon chest respectively. A lack of understanding of the ultrastructural and molecular biology properties of costal cartilage is a major confounder in predicting causes and outcomes of these disorders. Due to the avascular nature of cartilage, chondrocytes metabolize glycolytically, producing an acidic environment. During physical activity hydrogen ions move within cartilage driven by compressive forces, thus at any one time, chondrocytes experience transient changes in pH. A variety of ion channels on chondrocytes plasma membrane equip them to function in the rapidly changing conditions they experience. In this paper we describe reduced expression of the ASIC2 gene encoding the acid sensing ion channel isoform 2 (previously referred to as ACCN1 or ACCN) in patients with chest wall deformities. We hypothesized that chondrocytes from these patients cannot respond normally to changes in pH that are an integral part of the biology of this tissue. Activation of ASICs indirectly creates a cascade ultimately dependent on intracellular calcium transients. The objective of this paper was to compare internal calcium signaling in response to external pH changes in costal chondrocytes from patients with chest wall deformities and healthy individuals. Although the molecular mechanism through which chondrocytes are regulated by acidosis remains unknown, we observed reduced amplitudes of calcium rise in patient chondrocytes exposed to low pH that become further impaired upon repeat exposure.

[Costal cartilage changes in children with pectus excavatum and pectus carinatum]. / Izmeneniia rebernogo khriashcha pri voronkovidnoi i kilevidnoi deformatsii grudnoi kletki u detei.

Pectus excavatum (PE) and pectus carinatum (PC) in children are the most common congenital deformities that cause complications in the thoracic organs; however, the role of chondrocytes and cartilage canals in the pathogenesis of these conditions remains unexplored. OBJECTIVE: To investigate qualitative and quantitative changes of cartilage lacunae and canals in the costal cartilages in children with PE and PC compared to those with normal chests. SUBJECT AND METHODS: Costal cartilages were investigated in 10 children with normal chests (a control group), in 12 children with PE, and in 12 children with PC. Tissue fragments were fixed in 10% neutral formalin and embedded in compacted paraffin. Sections were stained with hematoxylin and eosin. Slides were examined by light microscopy. Cartilage lacunae, hyper- and hypolacunar zones, and cartilage canals were morphometrically examined, followed by statistical data analysis. RESULTS: There was a significant decrease in the number of cartilage lacunae and in the frequency of hyperlacunar zones and an increase in that of hypolacunar zones in the PE and PC groups. There were no significant differences in these parameters between the PE and PC groups; however, there was a tendency to the smallest number of cartilage lacunae and canals in the PC group and that to the preponderance of empty lacunae in the PE group. Only the PC group showed also negative correlations between the proportions of empty lacunae and the age of children. CONCLUSION: The pathogenesis of PE and PC in children is related to the impaired trophism of costal cartilages due to the smaller number of cartilage channels containing vessels and lacunae with chondrocytes. The development of PE and PC is associated with specific costal cartilage morphological changes that suggest that PE and PC are different manifestations of the same disease, namely connective tissue dysplasia.

Influence of rib impact on thoracic gunshot trauma.

INTRODUCTION: The influence of rib impact on thoracic gunshot trauma remains unclear, despite its high occurrence. This study therefore investigates the effect of rib impact on a bullet's terminal properties and injury severity. METHODS: Two bullets were used: 5.56×45 mm (full charge and reduced charge) and 7.62×51 mm (full charge). For each bullet, three impact groups were tested: (1) plain 10% ballistic gelatin (control) conditioned at 4°C, (2) intercostal impact, and (3) rib impact, the latter two tested with samples of porcine thoracic walls embedded in gelatin. Analysis included penetration depth, trajectory change, yaw, fragmentation, velocity reduction, energy deposition and temporary and permanent cavity characteristics. RESULTS: No significant differences were observed for most variables. Differences were found between rib (and intercostal) impact and the control groups, suggesting that the inclusion of thoracic walls produces an effect more significant than the anatomical impact site. Effects were ammunition specific. For the 7.62×51 mm round, rib impact caused an earlier onset of yaw and more superficial permanent gelatin damage compared with plain gelatin. This round also formed a larger temporary cavity on rib impact than intercostal impact. Rib (and intercostal impact) created a smaller temporary cavity than the control for the 5.56×45 mm round. For the reduced-charge 5.56×45 mm round, rib and intercostal impact produced greater velocity reduction compared with plain gelatin. CONCLUSIONS: This study provides new insights into the role of rib impact in thoracic gunshot injuries, and indicates that the effects are ammunition dependent. Unlike the 5.56×45 mm rounds, rib impact with the 7.62×51 mm rounds increases the risk of severe wounding.

Complex Suicide by Self-stabbing and Drowning: A Case Report and a Review of Literature.

Sharp force injuries and drowning are methods exceptionally combined in complex suicides. We report a challenging case of complex suicide by self-stabbing and drowning that illustrates the difficulty in discriminating between homicide and suicide in such circumstances of death. The corpse of a young man was found submerged in a river, stabbed nine times with two wounds that had penetrated the thorax and had caused lung injuries and a hemopneumothorax. The postmortem and histological examinations were consistent with a death caused by drowning, but the manner of death still remained undetermined. Police investigation finally concluded to a suicide, although no suicide note had been left and the victim had no underlying diagnosed mental disorder. The parameters that may help distinguish suicide from homicide at the autopsy should be interpreted in light of a thorough forensic investigation to determine the exact manner of death in such a case.

Dystrophic Mineralization of Costal Cartilage in Hartley Guinea Pigs.

Hartley guinea pigs are widely used animal models of disease, particularly in studies of osteoarthritis. The purpose of this study was to investigate lesions in the costal cartilage from 16 male, 5- to 6-month-old Hartley guinea pigs. Routine histological sections from the costal cartilage and costochondral junction (longitudinal and cross sections) and sternum (for evaluation of bone marrow) were examined. All 16 (100%) animals had histological lesions involving the costal cartilage that included matrix degeneration and mineralization, reduced cellularity, and evidence of chondrocyte necrosis. Of the 16, 4 (25%) of the lesions contained blood vessels and 3 (19%) contained central osseous metaplasia. The cartilage lesions were accompanied by degeneration (sometimes with regeneration and/or fibrosis) in adjacent skeletal muscle in 15 of the 16 (94%) animals. The lesions in the costal cartilage were interpreted as dystrophic mineralization of unknown cause and appear to be incidental findings, although they bear some resemblance to lesions occurring in Tietze's disease in humans. The significance of the lesions in skeletal muscle is unclear. Histological lesions of cartilage matrix degeneration and mineralization in these sites have not, to our knowledge, been reported previously.

Costal cartilage graft with perichondrium, a possible anti-adhesive material.

BACKGROUND: Adhesion occurs as a part of the wound healing process, but it sometimes compromises patients' daily activities. The authors were looking for materials and methods that could prevent adhesion, and noticed that the costal cartilage has possibility. The anti-adhesive property of the costal cartilage was examined histologically. METHODS: Thirty-five patients with microtia who provided consent for participating in this study were enrolled between April 2008 and March 2015. In the first stage of microtia reconstruction surgery, the excess cartilage was used to create these three types of specimens: (A) a piece of cartilage retaining the perichondrium on one side, (B) a piece of only cartilage parenchyma sliced with a plane parallel to the long axis of costal cartilage, and (C) the costal cartilage in a plane perpendicular to the long axis sliced pieces. These specimens were implanted into the subcutaneous fat of the chest. After at least 6 months in the second stage of surgery (i.e. auricular elevation), these specimens, wearing a little around the adipose tissue, we removed and examined histologically. RESULT: A fibrosis formation of the perichondrium side of Specimen A was thicker significantly than that of the cartilage side. A fibrosis formation of Specimen B was thicker significantly than that of the cartilage side of Specimen A. CONCLUSION: It was suggested that, if there is perichondrium, the costal cartilage parenchyma surface makes less adhesion with surrounding tissues. Costal cartilage with unilateral perichondrium is likely to be an effective surgical material for adhesion prevention.

Effects of platelet-rich plasma on cartilage regeneration after costal cartilage resection: a stereological and histopathological study.

BACKGROUND: In cases of congenital chest wall deformities, it is important to maintain the flexibility of the chest wall after rib cartilage resection. In this study, we aimed to determine the regeneration capability of cartilage and the effects of platelet-rich plasma (PRP) on the regeneration process. METHODS: A total of 16 four-week-old New Zealand rabbits were used in this study. In the 4th-5th right costal cartilages, the perichondrial sheaths were dissected and costal cartilages were excised. Then, the perichondrial sheaths were closed with absorbable material in the sham group (n = 8), and this was done after replacing PRP in the PRP group (n = 8). The left costal cartilages of the animals were used as controls. The volumes of the costal cartilages and their perichondrial sheaths were estimated using Cavalieri's principle. In addition, the mean numerical densities of the chondroblasts and chondrocytes per square millimetre were estimated using unbiased counting frames. RESULTS: In the PRP and sham groups, the volumes of the cartilages and perichondrial sheaths were higher than those of the control group (p < 0.05). The numerical densities of the chondroblasts and chondrocytes increased more in the PRP group than in the sham group (p < 0.05). CONCLUSIONS: Applying PRP after resection may provide better healing and faster regeneration of cartilage.

Eficácia das técnicas estruturada e convencional na abordagem estética e reparadora do nariz / Efficacy of structured and conventional techniques on aesthetic and corrective rhinoplasty

Introdução: A rinoplastia, como outras subespecialidades da Cirurgia Plástica, apresentou evolução muito grande nas últimas décadas, tanto em termos de técnica operatória quanto em diagnóstico das alterações a serem tratadas. O objetivo deste trabalho é avaliar a eficácia das técnicas Estruturada e Convencional na abordagem estética e reparadora do nariz. Métodos: Foram estudados de forma retrospectiva 49 pacientes operados pelo autor do trabalho, que foram submetidos a uma das duas técnicas operatórias. A eficácia das técnicas foi avaliada a partir da crítica dos pacientes e do cirurgião com relação aos resultados e à capacidade de se chegar ao objetivo do pré-operatório. Resultados: Ambas as técnicas se mostraram eficazes para alcançar o objetivo final da cirurgia. A satisfação dos pacientes e do cirurgião foram semelhantes nos dois casos, e não houve complicações maiores em nenhum dos grupos. Conclusão: O trabalho mostrou que tanto a técnica Estruturada quanto a Convencional são eficazes para o tratamento das alterações nasais, sendo o mais importante o correto diagnóstico pré-operatório das alterações para a escolha da melhor abordagem em cada caso.

Introduction: Rhinoplasty, like other plastic surgery subspecialties, has greatly evolved in recent decades, as both a surgical technique and a diagnosis of the alterations that need to be performed. The objective of the current study was to evaluate the efficacy of the structured and conventional surgical techniques on nasal aesthetic and corrective approaches. Methods: A total of 49 patients, who underwent surgical operation by the author of this work, were retrospectively studied. The patient generally underwent one of the two surgical techniques. The efficacy of each technique was evaluated by means of the critique provided by the patients and the surgeon regarding the results, and the ability to reach the pre-operative goals. Results: Both techniques were efficient in attaining the final objective of the surgery. Patient and surgeon satisfaction were similar in both cases, and there were no major complications in any of the groups. Conclusion: The present work showed that both the structured and the conventional techniques were efficient in the treatment of nasal alterations. The most important factor for selecting the best approach in each case was the correct pre-operative diagnosis of the required alterations.

Dual-Energy CT of Urate Deposits in Costal Cartilage and Intervertebral Disks of Patients With Tophaceous Gout and Age-Matched Controls.

OBJECTIVE: The purpose of this study was to investigate whether monosodium urate (MSU) deposits could be identified within the abdomen and axial skeleton of patients with tophaceous gout using dual-energy CT (DECT). CONCLUSION: DECT of the abdomen, chest wall, and spine revealed extensive MSU deposits in costal cartilages and, to a lesser extent, intervertebral disks in the male patients with gout in our study. These were quantified volumetrically. However, age-matched control subjects showed similar deposits, indicating this was not a disease-specific finding. Thus, MSU deposition in the axial skeleton may be physiologic in middle-aged men.

Characteristics and time-dependence of cut marks and blunt force fractures on costal cartilages: an experimental study.

PURPOSE: The distinction between cut marks and blunt force injuries on costal cartilages is a crucial issue in the forensic field. Moreover, a correct distinction may further be complicated by decomposition, so the need arises to investigate the distinctive features of lesions on cartilage and their changes over time. METHODS: This study aimed to assess the stereomicroscopic features of cut marks (performed with six different knives) and blunt fractures (performed with a hammer and by means of manual bending) on 48 fragments of human costal cartilages. Moreover, in order to simulate decomposition, the cut and fractured surfaces were checked with stereomicroscopy and through casts after 1 and 2 days, 1 week, and 1, 2 and 4 months of drying in ambient air. RESULTS: In fresh samples, for single and unique cuts, striations were observed in between 44 and 88% of cases when non-serrated blades were used, and between 77 and 88% for serrated blades; in the case of "repeated" (back and forth movement) cuts, striations were detected in between 56 and 89% of cases for non-serrated blades, and between 66 and 100% for serrated blades. After only 1 week of decomposition the detection rates fell to percentages of between 28 and 39% for serrated blades and between 17 and 33% for non-serrated blades. Blunt force injuries showed non-specific characteristics, which, if properly assessed, may lead to a reliable distinction between different cut marks in fresh samples. The most evident alterations of the structure of the cartilage occurred in the first week of decomposition in ambient air. After one week of drying, the characteristics of cut marks were almost undetectable, thereby making it extremely challenging to distinguish between cut marks, blunt force fractures and taphonomic effects. CONCLUSION: The study represents a contribution to the correct assessment and distinction of cut marks and blunt force injuries on cartilages, providing a glimpse on the modifications such lesions may undergo with decomposition.

[The morphological and morphometric study of amianthoid transformation of the costal cartilage in health and in keeled chest deformity in children]. / Morfologicheskoe i morfometricheskoe issledovanie amiantoidnoi transformatsii rebernykh khryashchei v norme i pri kilevidnoi deformatsii grudnoi kletki u detei.

Amianthoid transformation (AT) is the accumulations of abnormal collagen structures (amianthoid fibers) in the hyaline cartilages, tumors, and tendons. Neither functional value of costal cartilage matrix AT, nor its role in the pathogenesis of congenital chest deformities is known now. AIM: to examine the morphological features of AT in the costal cartilage of children with the normal and keeled chest. SUBJECTS AND METHODS: Costal cartilages were studied in 6 children with the normal chest (autopsy material) and in 5 ones with keeled chest (surgical material). Tissue fragments were fixed in 10% neutral formalin and embedded in compacted paraffin. The sections were stained with hematoxylin and eosin, picrofuchsin by van Gieson, with picrosirius, toluidine blue and by the Malaurie method modified by Gallego. The specimens were examined by light, phase-contrast, dark-field, fluorescence, and polarization microscopy. The frequency of AT sites and their area were morphometrically studied and the findings were then statistically processed. RESULTS: Various types of AT in the costal cartilages were described as both the normal and keeled chest. According to their morphological features, classic, fine-fiber, twisted, and intralacunar types were identified. There were statistically significant increases in the incidence of all types (except the intralacunar one) and in the area of the fine-fiber AT type in keeled chest deformity as compared to health. There were positive correlations between the area of classic, intralacunar, and twisted types in both groups and between the area of a classic type and age in the controls. CONCLUSION: A classification of AT areas varying in structures in health and disease has been given for the first time; their relation to each other and to the presence of keeled deformity shown, which, in our opinion, suggests that AT is implicated in the pathogenesis of the disease.

[PRELIMINARY HISTOLOGICAL OBSERVATION OF EFFECT OF EXPANDED CAPSULE ON COSTAL CARTILAGE AUTOGRAFT].

OBJECTIVE: To explore the effect of the expanded capsule on the growth of autogenous costal cartilage. METHODS: Sixteen New Zealand white rabbits at the age of 3 months (weighing, 2.2-2.5 kg; male or female) were selected and four 15 mL tissue expanders were implanted on the back symmetrically. After 1 month, the expanded capsule formed, the tissue expanders were removed; the capsule of the left side was removed (experimental group), and the capsule of the right side was reserved (control group); meanwhile, the right 7th and 8th costal cartilage without the perichondrium was divided into segments and placed into the capsule of 2 groups symmetrically. At 4 and 8 weeks after transplantation, the cartilage was harvested for the general, weighing, and histological observations. RESULTS: One rabbit died during the experiment, and the other 15 rabbits survived. The differences of cartilage weight between before and after transplantation showed more obvious increase in the experimental group [(0.003 4 ± 0.002 7) g and (0.005 8 ± 0.001 4) g] than those in the control group [(-0.000 3 ± 0.001 9) g and (-0.003 9 ± 0.005 3) g] at 4 and 8 weeks, showing significant differences between 2 gouprs (t = 4.331, P = 0.029; t = 6.688, P = 0.008). The change of cartilage weight at 8 weeks was significantly higher than that at 4 weeks in the experimental group (t = -3.098, P = 0.001); but the change of cartilage weight at 8 weeks was significantly lower than that at 4 weeks in the control group (t = 2.491, P = 0.009). The histological observation showed that the activity of the cartilage was enhanced in 2 groups at 4 and 8 weeks when compared with normal cartilage, and more obvious change was observed in the experimental group than in the control group. And the acellular area was seen in the cartilage at 8 weeks in the control group. The Masson staining results showed that the color was deeper in the experimental group than in the control group. CONCLUSION: The removal of the expanded capsule during operation is beneficial to the growth of autogenous costal cartilage. The results can provide corresponding experimental guidance for the clinical problems.