Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling.

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method. This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture's morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures. Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels. Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.

Elastic Stable Chest Repair as a Means of Stabilizing the Anterior Chest Wall in Recurrent Pectus Excavatum with Sternocostal Pseudarthrosis: An Innovative Fixation Device.

INTRODUCTION: Open surgical procedures in the treatment of pectus excavatum (PE) involve predetermined incisions in the parasternal cartilage and the bony ribs. For some procedures, the ribs are even dissected from the sternum for better sternal mobilization and thus better elevation of the funnel. Secure restoration of the sternocostal junction is then required, with the consequence that healing may be quite impaired. Patients may also subsequently suffer from sternocostal nonunion, for example, pseudarthrosis, and dislocated ribs, as well as pain and a recurrence of PE. MATERIALS AND METHODS: Patients underwent another open surgery with revision of the pseudarthrotic sternocostal junctions and sufficient mobilization of the anterior chest wall, followed by an open reduction and internal fixation using Matrix Rib titanium plates (Synthes, Oberdorf, Switzerland). This procedure consisted of elevating the anterior chest wall and fixing the ribs to the sternum. In 2011 and 2012, we studied this procedure, known as elastic stable chest repair (ESCR), in a series of 20 patients. The patients underwent clinical and ultrasound examinations and X-ray radiographs after the operation, after 6 weeks, and at 3- and 12-month intervals. RESULTS: Follow-up showed high patient tolerance, although a loose plate was observed in one patient and a broken plate in three patients. A stable union was achieved for all sternocostal pseudarthroses. PE improved highly significantly (p < 0.001), as the Haller index decreased from 3.6 (range: 2.7-6.6, standard deviation [SD]: 0.92) to 2.7 (range: 2.0-3.7, SD: 0.42). Pain in the anterior chest wall was significantly reduced after the operation in the majority of cases. All but one patient was mobilized already the day after the operation. CONCLUSIONS: ESCR in recurrent PE achieved functional stabilization of the anterior chest wall combined with satisfactory results.

Innovative minimally invasive pediatric surgery is of therapeutic value for splenic injury.

BACKGROUND/PURPOSE: Until now, minimally invasive surgery (MIS) has not had any therapeutic status for operable splenic trauma, because reliable sealing of larger defects is not possible with general techniques. METHODS: Fleece-bound sealing allows rapid, large-area sealing of erosions and defects, so that with the aid of an MIS applicator system (AMISA), this method of tissue management can be transferred to MIS. RESULTS: An in vitro evaluation showed that liquid fibrin sealing (FS) exhibits incomplete selective leak closure and low adhesive strength (4.1 hPa) and is not suitable for challenging surfaces. Fleece-bound sealing (ready-to-use v. prepare-to-use) showed reliable sealing and higher adhesive strength for collagen fleeces that are ready coated with fibrinogen-based sealant (TachoComb H; Nycomed, Linz, Austria) compared with various carrier systems that had to be impregnated on the spot (prepare-to-use; 50.2 v 23 hPa; P <.0001). Between October 1993 and October 2001, 19 of 87 children with splenic rupture were treated with the AMISA system (AMISA + TachoComb H) (21.8%), and 3 of these children had multiple trauma. The operation was indicated because of circulatory instability despite adequate volume replacement therapy. Splenic repair always was possible with the AMISA system, a changeover and splenectomy was not necessary, and the postoperative course was complication free. The mean stay in the hospital was 9.2 days. CONCLUSIONS: The AMISA system efficiently expands the indications for emergency laparoscopy and can be used successfully in emergency laparoscopy for splenic rupture management.