The analgesic effects of combined bilateral parasternal block and serratus anterior plane block for coronary artery bypass grafting surgery.

BACKGROUND: Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). METHODS: Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www. CLINICALTRIALS: gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18-80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. RESULTS: The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. CONCLUSIONS: In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.

[Forensic age diagnosis by assessment of sternum ossification processes]. / Sudebno-meditsinskaya diagnostika vozrasta posredstvom otsenki protsessov ossifikatsii grudiny.

OBJECTIVE: To study the sternum ossification processes that take place over time as well as the possibilities of sternum X-rays application to evaluate the age on the modern Russian population in forensic terms. MATERIAL AND METHODS: Sternum X-rays with fragments of ribs' chondral parts were obtained from 369 male and female corpses aged 12-96 years without pathological and traumatic changes. The X-rays were done in frontal projection. The set of examined parameters included: complete and partial synostosis of manubrium and body, induration along the synostosis (or on the articulated edges of manubrium and body), complete and partial synostosis of body segments, traces of body segments union, complete and partial synostosis of body and xiphoid process, induration along the synostosis (or on the articulated edges of manubrium and body), form of costal notches, induration of articular edges of body, presence of calcification foci in sternal edge of II-VII ribs' cartilages, depth of sternum notches, overgrowths on articular edges of body, presence of union between body's costal notches and calcification centers of ribs' cartilages. Mean values, standard deviation and correlation coefficient were determined. RESULTS: The maximal correlation with age was found in such parameters such: overgrowths on articular edges of body (r=0.6), presence of calcification foci in sternal edge of II-VII ribs (r=0.6), induration of body's articular edges (r=0.5), presence of union between costal notches and calcification centers of ribs cartilages (r=0.5), synostosis of body and xiphoid process (r=0.4). CONCLUSION: A subsequent construction of linear model for age diagnosis has its details when comparing the predicted age with the real.

Sternal Morphologic Characteristics of U.S. Military Males by Computed Tomography: Implications for Intraosseous Access.

INTRODUCTION: Sternal intraosseous (IO) access has advantages over humeral and tibial access for fluid resuscitation in military medical settings due to superior flow rates and pharmacokinetics. However, the morphology of the young adult manubrial cortical and medullary bone as it relates to IO catheter tips of currently available FDA-approved IO access devices is unclear. MATERIALS AND METHODS: Computed tomography manubrium images of active duty service members (N = 93) aged 18 to 30 were assessed by radiologists, including manubrial height, width, and cortical thickness, as well as total thickness and medullary thickness at the thickest (superior) and thinnest (inferior) parts of the manubrium. Inference regarding medullary or cortical IO catheter tip placement rates were made for FAST1 (5.5 mm catheter depth) and TALON (4.5 mm catheter depth) sternal IO devices. Data were analyzed using ANOVA, non-parametric, and correlational statistics at P < 0.05. RESULTS: As inferred from case-specific CT-derived manubrium dimensions and maximal catheter tip penetration depths, both FAST1 and TALON would be placed in the target medullary space on 100% of opportunities if properly applied in the superior manubrium and on 99% of opportunities if properly applied in the inferior manubrium. Age was not significantly related to IO-relevant manubrial dimensions. CONCLUSIONS: Present findings suggest that both FAST1 and TALON sternal IO catheter tips can be successfully placed into the target medullary bone with high accuracy in male military members aged 18 to 30 who require rapid resuscitation.

A heart transplant and concomitant hemiarch repair in a patient with a large ascending aortic aneurysm and a challenging sternal re-entry.

An orthotopic heart transplant and an aortic operation can be done concomitantly at centres that are experienced in both aortic operations and heart transplants with meticulous surgical strategy.

The pectus care guidelines: best practice consensus guidelines from the joint specialist societies SCTS/MF/CWIG/BOA/BAPS for the treatment of patients with pectus abnormalities.

Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care.

Three-dimensional modelling and printing in anterior chest wall reconstruction and stabilisation.

Anterior chest wall instability as a result of sternocostal non-union is a rare complication but can give rise to invalidating pain and cardiac arrhythmias. A woman in her 40s was referred to us with anterior chest wall pain and instability after a modified Ravitch procedure. Sternocostal pseudoarthrosis was seen for which multiple operations were performed which were complicated by low-grade infections. A patient-specific three-dimensional modelled and printed prostheses was used in an operation to both lift the sternum for pectus correction and to reconnect the sternum and the sternal costal junction to regain anterior chest wall stability.

[Postoperative sternomediastinitis: morphology of lesion, treatment strategy]. / Posleoperatsionnyi sternomediastinit: morfologiya porazheniya, taktika lecheniya.

OBJECTIVE: To analyze bone tissue damage at different stages of disease (El Oakley classification), treatment options for each clinical situation and results after each approach. MATERIAL AND METHODS: There were 45 patients with wound complications after cardiac surgery between October 2022 and September 2023. Thirty-eight (84.4%) patients underwent CABG, 7 (15.6%) patients - heart valve or aortic surgery. Mean age of patients was 68.1±10.3 years. There were 35 men (77.8%) and 10 women (22.2%). The first type was found in 11 (24.5%) patients, type 2-3 - 19 (42.2%), type 4 - 4 (8.8%), type 5 - 11 (24.5%) patients. RESULTS: Systemic inflammatory response syndrome was observed in 7 (36.8%) persons of the 1st group, 14 (73.7%) ones of the 2nd group, 4 (100%) patients of the 3rd group and 2 (18.2%) patients of the 4th group. C-reactive protein and procalcitonin increased in all patients with the highest values in groups 2 and 3. Redo soft tissue inflammation occurred in all groups after treatment. Mean incidence was 25%. Two (10.5%) patients died in the 2nd group and 1 (25%) patient in the 3rd group. CONCLUSION: The modern classification of sternomediastinitis does not fully characterize severity of disease in a particular patient. Simultaneous debridement with wound closure demonstrates acceptable mortality (within 10%). The highest mortality rate was observed in patients with diffuse lesions of the sternum. Less aggressive treatment approaches are possible for stable anterior chest wall.

Risk factors for sternal wound infection after median sternotomy: A nested case-control study and time-to-event analysis.

Although potential risk factors for sternal wound infection (SWI) have been extensively studied, the onset time of SWI and different risk factors for superficial and deep SWI were rarely reported. This nested case-control study aims to compare the onset time and contributors between superficial and deep SWI. Consecutive adult patients who underwent cardiac surgery through median sternotomy in a single center from January 2011 to January 2021 constituted the cohort. The case group was those who developed SWI as defined by CDC and controls were matched 6:1 per case. Kaplan-Meier analysis, LASSO and univariate and multivariate Cox regressions were performed. A simple nomogram was established for clinical prediction of the risk of SWI. The incidence of SWI was 1.1% (61 out of 5471) in our cohort. Totally 366 controls were matched to 61 cases. 26.2% (16 of 61) SWI cases were deep SWI. The median onset time of SWI was 35 days. DSWI had a longer latency than SSWI (median time 46 days vs. 32 days, p = 0.032). Kaplan-Meier analyses showed different time-to-SWI between patients with and without DM (p = 0.0011) or MI (p = 0.0019). Multivariate Cox regression showed that BMI (HR = 1.083, 95% CI: 1.012-1.116, p = 0.022), DM (HR = 2.041, 95% CI: 1.094-3.805, p = 0.025) and MI (HR = 2.332, 95% CI: 1.193-4.557, p = 0.013) were independent risk factors for SWI. Superficial SWI was only associated with BMI (HR = 1.089, 95% CI: 1.01-1.175, p = 0.027), while deep SWI was associated with DM (HR = 3.271, 95% CI: 1.036-10.325, p = 0.043) and surgery time (HR = 1.004, 95% CI: 1.001-1.008, p = 0.027). The nomogram for SWI prediction had an AUC of 0.67, good fitness and clinical effectiveness as shown by the calibration curve and decision curve analyses. BMI, DM and MI were independent risk factors for SWI. DSWI had a longer latency and different risk factors compared to SSWI. The nomogram showed a fair performance and good effectiveness for the clinical prediction of SWI.

[Morphology of sternum for formation of the biological profile of unidentified individual]. / Morfologiya grudiny dlya formirovaniya biologicheskogo profilya neopoznannogo individa.

Identification of a person by general group characteristics does not lose its relevance over a long period. An analysis of publications (2000-2023) devoted to the possibilities of using the sternum to determine gender and age showed a fairly large amount of work on this topic, with very promising results. The trend in the development of this area is the use of modern methods of medical imaging. This becomes the starting point for conducting such studies on the territory of the Russian Federation and developing a methodology that includes the Russian population, taking into account their population characteristics.

Tumor de células gigantes esternal: esternectomía total y reconstrucción con barras de titanio más malla de polipropileno / Sternal Giant Cell Tumor: Total Sternectomy and Reconstruction with Titanium Rods Plus Polypropylene Mesh

El tumor de células gigantes (TCG) constituye un tumor óseo benigno relativamente frecuente. Se caracteriza por ser localmente agresivo y el lugar de presentación más frecuente es a nivel del esqueleto axial (fémur distal o tibia proximal). Hasta la actualidad, existen escasos informes de presentaciones atípicas, como a nivel del esternón. En este informe, se presenta el caso de una paciente mujer de 24 años que presenta tumoración indurada a nivel de la región esternal de crecimiento progresivo asociado a dolor. Los hallazgos radiológicos revelan tumoración osteolítica que tiene como origen el cuerpo del esternón y lo compromete casi en su totalidad. Este se proyecta hacia las partes blandas y llega al plano superficial. Debido a la extensión de la enfermedad y al compromiso extenso en el cuerpo del esternón, se realiza la resección del cuerpo y manubrio esternal. El defecto es reconstruido con malla de polipropileno, barras de titanio, parche de epiplón y autoinjerto de piel; se obtiene una adecuada estabilidad de la caja torácica y resultados estéticos favorables. El caso tiene un adecuado manejo oncológico puesto que la resección es completa con márgenes microscópicos libres (resección R0).

Giant cell tumor (GCT) constitutes a relatively common benign bone tumor, characteri-zed by its local aggressiveness. The most frequent site of occurrence is in the axial ske-leton (distal femur or proximal tibia). To date, there have been few reports of atypical presentations, such as at the level of the sternum. In this report, we present the case of a 24-year-old female patient who presented with an indurated mass in the sternal region, progressively growing and associated with pain. Radiological findings revealed an osteolytic mass originating from the body of the sternum, involving almost its entire extent and projecting into the soft tissues, reaching the superficial plane. Due to the extent of the disease and the extensive involvement of the sternal body, resection of the body and manubrium of the sternum was performed. The surgical defect was reconstructed with polypropylene mesh, titanium bars, an omental patch and a skin graft, achieving adequate stability of the thoracic cage and favorable cosmetic results.

Pectus Disorders: Excavatum, Carinatum and Arcuatum.

This article reviews pectus excavatum, carinatum, and arcuatum. Topics covered include etiology, epidemiology, associated syndromes, physiologic impact, workup, indications for treatment, surgical and nonsurgical therapy, results, complications, and emerging therapies. Pectus excavatum is an inward deformation of the sternum and/or anterior chest wall. Pectus carinatum is ether an outward protrusion or tilt of the sternum with potential psychological impact, but no demonstrated physiologic impact. Nonoperative compression bracing is successful in carinatum patients with chest wall flexibility who are compliant with a bracing program. Pectus arcuatum is an abnormally short, fully fused sternum with a high anterior protrusion.

Surgical fixation of traumatic sternal manubrium dislocation and right-sided rib fractures following a motorcycle accident.

This brief report discusses the diagnosis, management and surgical intervention of a man in his 30s presenting with a rare traumatic sternal manubrium dislocation following a motorcycle crash, accompanied by multiple concomitant rib fractures. The severity and complexity of the patient's injuries necessitated an operative approach for his sternomanubrial dislocation, emphasising the importance of multidisciplinary coordination, accurate diagnosis and prompt surgical intervention. The report provides valuable insights into the successful application of open reduction and internal fixation with plating in a real-world setting, which resulted in positive patient outcomes, despite the rarity and severity of this type of trauma. It further underscores the need for additional research to advance best practices for managing traumatic sternal manubrium dislocations in the context of high-impact injuries.

Antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management for sternal infection after midline sternotomy.

INTRODUCTION: Deep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI. METHODS: We retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed. RESULTS: All patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps. CONCLUSIONS: We report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.

The The Sandwich Technique For Minimally Invasive Repair Of Pectus Carinatum.

INTRODUCTION: Minimally invasive repair of pectus carinatum (MIRPC) has been performed using the Abramson technique in which the bar that compresses the sternum is fixed with steel wires on the ribs. A 14-year-old patient underwent to a MIRPC using a sandwich technique in which two metallic bars fixed with bridges were implanted below the sternum under thoracoscopic vision, and another bar in a subcutaneous tunnel was implanted above. This technique has the potential to avoid specific problems related to the original technique like loosening of support for correction (broken wire), avoidance of induction of pectus excavatum or subcutaneous tissue adhesion.

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.

Utilizing 3-dimensional models to assess keel bone damage in laying hens throughout the lay cycle.

The global egg industry is rapidly transitioning to cage-free egg production from conventional cages. Hens housed in cage-free systems have an increased prevalence of keel damage that could lead to reduced egg production and compromised well-being. The objective of this study was to determine the effects of dietary supplementation of n-3 fatty acids and vitamin D3 on keel damage in hens housed in multi-tier aviary systems (AV). Brown hens were placed in 4 AV system rooms after rearing at 17 wk of age (woa) with each room containing 576 birds. At 12 woa, rooms were randomly assigned to a dietary treatment of flaxseed oil, fish oil, vitamin D3, or control. Focal birds (36 per treatment) were longitudinally examined for keel damage using quantitative computed tomography (QCT) at nine timepoints from 16 to 52 woa. Three-dimensional digital twins of the keels were created from the QCT scans and visually assessed for damage. An overall keel severity score was recorded as well as the location, direction, and severity of each deviation or fracture. Severity was ranked on a 0 to 5 scale with 0 being no damage and 5 being severe. Damage scores were analyzed utilizing odds ratios with main effects of age and treatment. At 16 woa, 80% of hens had overall keel scores of 0 and 20% had scores of 1. At 52 woa, all hens had damage, with 31% having a score of 1, 61% scored 2 to 3, and 8% scored 4 to 5. Most fractures were not observed until peak lay. Dietary treatments did not affect likelihood of fracture incidences, but younger birds had lower odds of incurring keel fractures than older birds (P < 0.0001). The initial incidences of keel deviations occurred earlier than fractures, with most birds obtaining a keel deviation by 28 woa. Keel damage was not able to be prevented, but the age at which keel fractures and deviations initiate appear to be different, with deviations occurring during growth and fractures during lay.

Favourable outcome in survivors of CPR-related chest wall injuries.

BACKGROUND: There is a lack of studies focusing on long-term chest function after chest wall injury due to cardiopulmonary resuscitation (CPR). The purpose of this cross-sectional study was to investigate long-term pain, lung function, physical function, and fracture healing after manual or mechanical CPR and in patients with and without flail chest. METHODS: Patients experiencing out-of-hospital cardiac arrest between 2013 and 2020 and transported to Sahlgrenska University Hospital were identified. Survivors who had undergone a computed tomography (CT) showing chest wall injury were contacted. Thirty-five patients answered a questionnaire regarding pain, physical function, and quality of life and 25 also attended a clinical examination to measure the respiratory and physical functions 3.9 (SD 1.7, min 2-max 8) years after the CPR. In addition, 22 patients underwent an additional CT scan to evaluate fracture healing. RESULTS: The initial CT showed bilateral rib fractures in all but one patient and sternum fracture in 69 %. At the time of the follow-up none of the patients had persistent pain, however, two patients were experiencing local discomfort in the chest wall. Lung function and thoracic expansion were significantly lower compared to reference values (FVC 14 %, FEV1 18 %, PEF 10 % and thoracic expansion 63 %) (p < 0.05). Three of the patients had remaining unhealed injuries. Patients who had received mechanical CPR in additional to manual CPR had a lower peak expiratory flow (80 vs 98 % of predicted values) (p=0.030) =0.030) and those having flail chest had less range of motion in the thoracic spine (84 vs 127 % of predicted) (p = 0.019) otherwise the results were similar between the groups. CONCLUSION: None of the survivors had long-term pain after CPR-related chest wall injuries. Despite decreased lower lung function and thoracic expansion, most patients had no limitations in physical mobility. Only minor differences were seen after manual vs. mechanical CPR or with and without flail chest.