New Computerized Planning Algorithm and Clinical Testing of Optimized Nuss Bar Design for Patients with Pectus Excavatum.

BACKGROUND Computer-aided design (CAD) has been used in the Nuss procedure to determine the bar length and shape. Despite computer aid, the shape and design remain quite intuitive. We tested a new algorithm to determine the optimal bar shape. MATERIAL AND METHODS The normal sterno-vertebral distance was defined on computed tomography (CT) scans of patients without pectus excavatum (PEx) at the same level where the deepest depression was found on CT scans of 97 patients with PEx. Four points were marked on the CT scan of 60 patients with PEx at the deepest deformity: P1: edge of the vertebra; P2: edge of the deformity; P3: the expected contact point of the bar and the rib; and P4: the expected end of the bar. The algorithm generated 3 circles upon these points, and the fusion of the arcs drew the line of the ideal bar. Corrected and normal sterno-vertebral distance values were compared with the Mann-Whitney U test. Ten bars were bent manually guided by a 1: 1 printout of the designed bar and were implanted in 10 adolescents. RESULTS The shortest sterno-vertebral distance was 3 cm below the intermammillary line in PEx patients. The normal mean sterno-vertebral distance at this level was 10.16±1.35 cm in non-PEx patients. The mean virtually corrected sterno-vertebral distance was 10.28±1.27 cm. No significant difference was found (P=0.44). The bars were seamless and were successfully implanted. No bar needed adjustment, the operation time was shorter, and the patient satisfaction score was 9.4/10. CONCLUSIONS With our new algorithm, an optimal Nuss bar can be designed.

Development of an Algorithm to Determine Which Costal Cartilage to Harvest.

Rib graft is a common source of cartilage in rhinoplasty. Donor site choices for this resource were identified according to the authors who presented the introduction of this technique. However, the scientific basis of this valuable method lacks information, including the anatomical properties of costal cartilage. In this study, cartilage radioanatomy is examined and tested for if any estimators are present. A total of 148 thoracal CT scans of patients who applied to our facility were analyzed. Patients were divided per their sex and age of 35, and rib cartilage dimensions, including axial length between the sternal and costal ends of the cartilage (TotL), posteroanterior diameters at the sternal end (StDia), costal end (CosDia), the thickest part (MaxDia) as diametrical parameters and vertical height at the thickest part (h) were recorded. Length of the sternum (St), the axial length of the clavicle (ClavL), the distance of the sixth rib from the anterior axillary border (AntAx), and thorax circumferences at the level of both pectoralis major muscle origin (ThC) and nipples (BrC) were recorded. Statistical analyses were done for correlations. St, ClavL, ThC, and BrC were found to have the most correlated measurements in groups with the age of 35 and less of both genders, and the relations were lost in older groups. Thorax shape may change after the age of 35 years, but in younger patients, St in females and ClavL in males can be used as estimators of cartilage amount.

A 1-Day-Old Girl With Infantile Hemangioma and Sternal Cleft.

CASE PRESENTATION: A newborn girl presented to the hospital on the first day of life because of respiratory failure. She was born at home at 37 weeks' gestation with minimal prenatal care and was found to be small for gestational age. The patient was found to have partial sternal agenesis and sternal cleft, cutis aplasia, left facial hemangioma, micrognathia, wide-spaced nipples, and low-set ears. The mother's and baby's urine toxicology screening were positive for amphetamines. Chest radiographs on admission showed bilateral hazy opacities. CT scan of the chest showed an absent sternum with midline chest wall concavity. The patient was monitored preoperatively in the cardiac ICU for risks of arrythmia, respiratory failure, altered cardiac output, and acute cardiopulmonary decompensation.

Computed Tomography Scanning for Sternal Wound Infections: A Systematic Review.

Background: Sternal wound infection (SWI) has always been a significant risk in patients who undergo sternotomies as part of their cardiac surgical procedures. Computed tomography (CT) imaging is often used to diagnose and assess sternal wound infections. Its purpose includes identifying and locating infection and any sternal dehiscence. Methods: A systematic literature review across PubMed, Embase, and Ovid was performed according to PRISMA guidelines to identify relevant articles that discussed the utility of CT scanning for SWI, common features identified, patient outcomes and sensitivity/specificity (Figure 1). Results: 25 papers were included. 100% (n=25) of the papers were published in peer-reviewed journals. CT scans in SWIs can be seen as a beneficial aid in diagnosing as well as determining the components of infection. Commonalities were identified such as fluid collection in the mediastinum, free gas, pleural effusions, and sternal dehiscence which point towards the presence of sternal wound infection. Conclusion: CT scanning is a novel and emerging methodology for imaging in SWI and post-sternotomy complications, hence increased research is required to expand the literature on this area as well as the creation of guidelines and cut-offs or signs for radiology professionals to identify and determine the extent of infection.

Adult age estimation from the sternum using maximum intensity projection images of CT and data mining in a Chinese population.

This study aimed to explore and develop data mining models for adult age estimation based on CT reconstruction images from the sternum. Maximum intensity projection (MIP) images of chest CT were retrospectively collected from a modern Chinese population, and data from 2700 patients (1349 males and 1351 females) aged 20 to 70 years were obtained. A staging technique within four indicators was applied. Several data mining models were established, and mean absolute error (MAE) was the primary comparison parameter. The intraobserver and interobserver agreement levels were good. Within internal validation, the optimal data mining model obtained the lowest MAE of 9.08 in males and 10.41 in females. For the external validation (N = 200), MAEs were 7.09 in males and 7.15 in females. In conclusion, the accuracy of our model for adult age estimation was among similar studies. MIP images of the sternum could be a potential age indicator. However, it should be combined with other indicators since the accuracy level is still unsatisfactory.

Sternal Pin Used to Close Sternum in Infants after Cardiac Surgery.

OBJECTIVE: A retrospective study was conducted to explore the efficacy of bioabsorbable poly-L-lactic acid sternal pins in sternal closure in infants after cardiac surgery. METHODS: A total of 170 infantile patients who underwent cardiac surgery were divided into the steel wire group (group A), the PDS cord group (group B), and the steel wire + sternal pin group (group C). The occurrence of the thoracic deformity was evaluated by vertebral index (VI), frontosagittal index (FSI), and Haller index (HI) values; the stability of the sternum was evaluated by detecting sternal dehiscence and displacement. RESULTS: By comparing the absolute values of the differences in VI, FSI, and HI in the three groups, it was found that the difference values of VI and HI in group C were significantly lower than those in group B (p = 0.028 and 0.005). For the highest deformation index, the deformation rate of infants in group C before discharge and during the 1-year follow-up was lower than that in group A and group B (p = 0.009 and 0.002, respectively). The incidence of sternal displacement in group C was also significantly lower than that in groups A and B (p = 0.009 and 0.009). During the 1-year follow-up, there was no sternal dehiscence, and the sternum healed completely in the three groups. CONCLUSION: The use of "steel wire + sternal pin" for sternal closure in infants after cardiac surgery can reduce the occurrence of sternal deformity, reduce anterior and posterior displacement of the sternum, and improve sternal stability.

A radiologist's guide to median sternotomy.

Median sternotomy is widely recognised as the primary incision technique in cardiac surgery. This surgical procedure involves dividing the sternum to gain access to the heart and lungs, making it invaluable in correcting congenital heart defects. Furthermore, it is frequently employed in adult patients, particularly during coronary artery bypass graft (CABG) procedures. In this imaging review, we present a comprehensive overview of the pre-procedural assessment and various post-sternotomy complications encountered within our clinical experience at a tertiary cardiothoracic centre. The focus of this review is to outline the imaging features associated with mediastinal adhesions and establish the minimal safe distance between the sternum and common mediastinal structures when considering re-sternotomy. By providing visual examples, we aim to facilitate a better understanding of these key concepts. Moreover, we delve into a detailed discussion of a spectrum of postoperative complications that may arise following median sternotomy including those related to metalwork (sternal wire fracture), bone (sternal dehiscence, non-union and osteomyelitis), and soft tissue (abscess, haematoma).

Sternal bone anatomy on preoperative imaging as an independent predictor of deep sternal dehiscence following median sternotomy.

Complications following median sternotomy are associated with morbidity, mortality, and major healthcare costs. With plastic surgeons being increasingly consulted to close complex sternotomy wounds, a more accurate risk stratification tool for this comorbid patient population is warranted. This study examines the association of preoperative radiologic sternal measurements and deep sternal dehiscence, comparing this with other known clinical risk factors. A decreased manubrium sternal thickness relative to body weight (<0.13 mm/kg) and an absolute inferior sternal width ≤13.8 mm had a significant association with the development of deep sternal dehiscence, even with adjustment for known clinical risk factors. With such measurements assisting in further risk stratification, the opportunity to improve risk assessment holds value for plastic and reconstructive surgeons who are consulted to close extensive sternotomy wounds.

Case Report of Complex Chest Wall Repair for Sternal Dehiscence After Bilateral Lung Transplantation.

BACKGROUND: We report a case of a complex chest wall reconstruction because of sternal dehiscence, requiring different surgical procedures for its complete resolution. CASE REPORT: A 54-year-old man patient with Langerhans cell histiocytosis and chronic obstructive pulmonary disease underwent bilateral sequential lung transplantation through a clamshell incision, using nitinol thermo-reactive clips for sternal closure. One year later, he consulted because of chest pain, fever, and purulent secretions. Physical examination and chest X-ray revealed a right pulmonary hernia due to post-clamshell wound dehiscence. Chest wall repair was performed, placing an expanded-polytetrafluoroethylene synthetic mesh, and the sternum was realigned and fixated with titanium plates and screws. However, in the immediate postoperative period, there was a large amount of serous drainage through the surgical wound, needing negative pressure therapy. Unfortunately, the wound became necrotic with exposure to the osteosynthesis material. In addition, a chest computed tomography scan showed fluid accumulation in the anterior chest wall. Therefore, two-stage revision surgery was indicated: first, the removal of the previous prosthesis and, the definite one, the use of a pedicled latissimus dorsi myocutaneous flap to provide effective coverage of the wound. CONCLUSION: Sternal dehiscence is not an uncommon complication after clamshell incision in patients undergoing bilateral sequential lung transplantation, and it is associated with significant morbidity. In the presence of chest wall instability, surgical repair is mandatory.

Surface anatomical landmarks for spine surgery: A CT-based study of the sternal notch and sternal angle in 1,035 patients.

BACKGROUND: Understanding the location of surface anatomical landmarks in relation to the cervical and thoracic spine is important for a wide array of clinical applications. The objective of this study was to investigate the influence of patient demographic and anthropometric characteristics on the locations of the sternal notch and sternal angle in relation to the spine using computed tomography (CT) of a large cohort of young adult patients without spinal pathology. METHODS: Vertebral levels corresponding to the sternal notch and sternal angle were analyzed using CT of 1,035 patients. Influences of patient height, weight, body mass index (BMI), sex, and ethnicity were assessed. RESULTS: 567 male and 468 female patients were included in this study. Mean patient height, weight, BMI, and age were 1.68 ± 0.11 m, 81.94 ± 24.39 kg, 27.79 ± 7.9 kg/m2, and 25.9 ± 5.9 years. Of the 1,035 patients, 495 were Hispanic or Latino, 321 were Caucasian, 130 were African American, 68 were Asian, 5 were identified as "other," and 16 did not have racial or ethnic data available. The location of the sternal notch in relation to the thoracic spine demonstrated a bimodal distribution pattern clustered at the T2 and T3 vertebral bodies. The location of the sternal angle in relation to the thoracic spine demonstrated a bimodal distribution pattern clustered at the T4 and T5 vertebral bodies. Moderate, negative correlations were observed between patient weight and location of the sternal notch (r = -0.447; p <.001) and sternal angle (r = -0.499; p <.001), respectively. Zero significant correlations were observed between patient height and location of the sternal notch (r = -0.045; p =.377) or sternal angle (r = -0.080; p =.229). A weak, negative correlation was observed between patient BMI and location of the sternal notch (r = -0.378; p <.001). A moderate, negative correlation was observed between patient BMI and location of the sternal angle (r = -0.445; p <.001). The locations of the sternal landmarks did not differ based on patient sex, race or ethnicity. CONCLUSIONS: The location of the sternal notch most frequently corresponds to the T2 or T3 vertebral body, while the sternal angle is most frequently located at the T4 or T5 vertebral body. Increased patient weight is associated with relatively cephalad sternal landmarks. Patient height, sex, and ethnicity are not associated with either sternal landmark.

Successful Medical Management of an Acute Traumatic Sternal Luxation in a Cat.

A 5 yr old indoor-outdoor domestic longhair red tabby cat presented for evaluation of a 1-day history of hiding, urinating and defecating outside the litterbox, and vocalizing when picked up. Physical examination revealed significant pain on palpation of the caudal sternum where an approximately 8 × 6 cm contusion was noted. Sedated thoracic radiographs revealed a luxated fifth intersternebral joint with the sixth sternebra being cranioventrally displaced (along with the seventh and eight sternebrae) to the level of the mid fourth sternebra. There were sharply marginated, short oblique fractures of the distal sixth costal cartilages bilaterally with mild dorsal displacement of the distal segment. The sternal luxation was palpated more aggressively once the patient was sedated and deemed to be stable. Because of the stability of the luxation and absence of sternebral fractures, conservative medical management in the form of analgesics and rest was instituted. Repeat thoracic radiographs 2 wk after presentation revealed an unchanged sternal luxation. Twelve months after presentation, the patient presented for an unrelated lameness and, in that timeframe, has exhibited no sequelae to the sternal luxation, which still palpates stable and is radiographically unchanged.

Pectus Arcuatum: A Pectus Unlike Any Other.

BACKGROUND: Pectus arcuatum is often mistaken for a type of pectus carinatum. However, pectus arcuatum is a unique clinical form of pectus caused by premature obliteration of the sternal sutures (manubrial sternum, four sternebrae and xiphoïd process), whereas pectus carinatum is due to abnormal growth of the costal cartilage. In order to better describe pectus arcuatum, we analysed the files of patients with pectus arcuatum followed in our centers. METHODS: Multicenter retrospective study of young patients' files diagnosed with pectus arcuatum. RESULTS: The clinical diagnosis of pectus arcuatum was made in 34 patients with a mean age at diagnosis of 10.3 years (4-23 years). A chest profile X-ray or a CT scan was performed in 16 patients (47%) and confirmed the diagnosis of PA by the presence of a sternal fusion. It was complete in 12 patients. A malformation was associated in 35% of cases (Noonan syndrome 33%, scoliosis 25% or cardiopathy 16%). 11 patients (32%) had a family history of skeletal malformation. Orthopedic treatment was initiated in 3 patients without any success. 11 patients underwent surgical correction, which was completed in 7 of them. CONCLUSION: The diagnosis of pectus arcuatum is based on clinical experience and if necessary, on a profile chest X-ray showing the fusion of the sternal pieces. It implies the search for any associated malformations (musculoskeletal, cardiac, syndromic). Bracing treatment is useless for pectus arcuatum. Corrective surgery, based on a sternotomy associated with a partial chondro-costal resection, can be performed at the end of growth. LEVEL OF EVIDENCE: IV.

Fully automated radiologic identification focusing on the sternal bone.

A crucial task in forensic investigations is the identification of unknown deceased. In general, secure identification methods rely on a comparison of ante mortem (AM) with post mortem (PM) data. However, available morphologic approaches are often dependent on the expertise and experience of the examiner, and often lack standardisation and statistical evidence. The objective of this study was therefore to overcome the current challenges via developing a fully automated radiologic identification (autoRADid) method based on the sternal bone. An anonymised AM data set consisting of 91 chest computed tomography (CT) scans, as well as an anonymised PM data set of 42 chest CT scans were included in this work. Out of the 91 available AM CT data sets, 42 AM scans corresponded to the 42 PM CT scans. For the fully automated identification analysis, a custom-made python pipeline was developed, which automatically registers AM data to the PM data in question using a two-step registration method. To evaluate the registration procedure and subsequent identification success, the image similarity measures Jaccard Coefficient, Dice Coefficient, and Mutual Information were computed. The highest value for each metric was retrieved in order to analyse the correspondence between AM and PM data. For all three similarity measures, 38 out of the 42 cases were matched correctly. This corresponds to an accuracy of 91.2%. The four unsuccessful cases incorporated surgical interventions taking place between the AM and the PM CT acquisition or poor CT scan quality preventing robust registration results. To conclude, the presented autoRADid method seems to be a promising fully automated tool for a reliable and facile identification of unknown deceased. A final pipeline combining all three similarity measures is open source and publicly available for efficient future identifications of unknown deceased.

Prevalence and morphometry of sternal and xiphoid foramen: a meta-analysis on 16,666 subjects.

PURPOSE: Sternal foramen is a perforation of the sternum that can be a source of misdiagnosis during radiographic imaging or life-threatening perforations during bone marrow sampling. The aim of this study was to conduct a meta-analysis on the prevalence, morphometrics, and location of foramen in the sternal body and xiphoid process, describe morphometric features of this phenomenon, and thus verify its clinical importance. Moreover, our secondary outcome was to compare effectiveness of various imaging methods in diagnosis of the sternal or xiphoid foramen. METHODS: A comprehensive search was conducted on major scientific databases to identify studies containing relevant information. Data on foramen's prevalence, location, morphometrics, and accompanying findings were extracted and pooled into a meta-analysis using MetaXL 5.0. RESULTS: Thirty-five studies (n = 16,666 subjects) were included. The overall pooled prevalence of a foramen in the sternal body and/or a xiphoid process was 8.9% (95% CI 6.5-11.7) and it equaled 6.5% (95% CI 5.6-7.6) for sternal body alone and 2.9% (95% CI 0.5-6.9) for the xiphoid process. The foramen was more prevalent in males than in females (12.2% vs. 6.8%). The prevalence of sternal foramen was higher in South American [13.9% (95% CI 11.2-16.9)] and African [13.6% (95% CI 9.7-18.0)] studies compared to North American [6.2% (95% CI 5.0-7.5)] and European populations [8.6% (95% CI 3.1-16.3)]. Mean transverse and vertical diameter of foramen equaled 4.7 mm (95% CI 3.8-5.5), and 5.6 mm (95% CI 4.2-6.9), respectively. CONCLUSION: Our analysis proves that the sternal foramina are structures of significant prevalence and size. Any physician should keep them in mind when performing punctures in this area.

Combined Repair of Upper Sternal Cleft and Pectus Excavatum in a Child.

Sternal cleft accompanied by pectus excavatum is a rare type of congenital anomaly of the chest wall. Surgical correction is a suitable approach to restore the heart, large vessels, and respiratory dynamics early. This is a report of the successful surgical correction of upper sternal cleft anomaly accompanied by pectus excavatum in a child. The pectus excavatum was corrected without the use of any prosthesis. The cleft was closed by primary approximation with enough dissected pectoralis major muscle and partial thymectomy, mobility, and flexibility ensured by pectus correction. The integrity of the sternum and the chest wall was normal at the end of the 12-month follow-up period.

Omental Flap for Complex Sternal Wounds and Mediastinal Infection Following Cardiac Surgery.

INTRODUCTION: Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons. METHODS: Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy. RESULTS: All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful. CONCLUSION: OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.