Wound complication after modified Ravitch for pectus excavatum: A case of conservative treatment enhanced by pectoralis muscle transposition

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Contents lists available atScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n a l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Wound

complication

after

modified

Ravitch

for

pectus

excavatum:

A

case

of

conservative

treatment

enhanced

by

pectoralis

muscle

transposition

Beatrice

Aramini

_,

_Uliano

_Morandi

_,

_Giorgio

_De

_Santis

_,

_Lucio

_Brugioni

_,

Alessandro

Stefani

_,

_Ciro

_Ruggiero

_,

_Alessio

_Baccarani

a_{DivisionofThoracicSurgery,DepartmentofMedicalandSurgicalSciencesforChildrenandAdults,UniversityofModenaandReggioEmilia,ViaLargodel}

Pozzo71-41124Modena,Italy

b_{DivisionofPlasticSurgery,DepartmentofGeneralSurgeryandSurgicalSpecialties.UniversityofModenaandReggioEmilia,ViaLargodelPozzo71,}

41124Modena,Italy

c_{InternalMedicineandCriticalCareUnit,DepartmentofIntegratedMedicine,EmergencyMedicineandMedicalSpecialties,UniversityofModenaand}

ReggioEmilia,ViaLargodelPozzo71,41124Modena,Italy

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Articlehistory:

Received1November2019 Receivedinrevisedform 23November2019 Accepted20December2019 Availableonline26December2019

Keywords: Pectusexcavatum Surgicaldebridement Woundinfection VACtherapy ModifiedRavitch

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INTRODUCTION:Multiplesurgicaldebridementsessionsaremandatorybeforewoundclosureincasesof infectionafteramodifiedRavitchprocedureforpectusexcavatum.Vacuum-assistedclosure(VAC)isa well-establishedtechnicalresourcefortreatingcomplicatedwounds;however,incasesofsuspicionof boneinfection,thisapproachisnotenoughtopreventbarremoval.

PRESENTATIONOFTHECASE:Wepresentacaseofsurgicalwounddehiscencewithhardwareexposureina patientwhohadundergonechondrosternoplastyforpectusexcavatum.Severalsessionsofdebridement (three)andVACwereappliedeverytime.Thefinalresultwasachievedwithoutthenecessitytoremove thehardware;however,toavoidtheriskofinfection,abilateralpectoralismuscleflapmobilizationwas performedasthefinalstepafterthesurgicalwoundrevisions,althoughthisapproachissuggestedto beusedduringthemodifiedRavitchprocedure.Thisapproachallowsforasignificantreductioninlate complicationsandimprovesmorphologicaloutcomes.

DISCUSSION:Insummary,thepectoralismuscleflaptranspositionisveryusefulnotonlyforaesthetical resultsbutalsoincombinationwithmultiplesurgicalrevisionsforconservativemanagementincase ofwoundinfectionduringamodifiedRavitchprocedure.Inourcase,thistechniquewasadoptedafter accuratecareofthewoundandbeforethefinalclosure,whichhelpstomaintaingoodvascularization andaverysatisfyingresult.

CONCLUSION:ItisimportanttoconsiderthisapproachduringthemodifiedRavitchprocedure,notonly forbetteraestheticalresultsbutalsotopreventinfectionsorwounddehiscenceatthelevelofthebar.

©2019TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

1. Introduction

Pectusexcavatumisastructuraldeformityoftheanterior tho-racicwallinwhichthesternumandribcageareshapedabnormally. Thisproducesacaved-inorsunkenappearanceofthechest.Itcan eitherbepresentatbirthordevelopafterpuberty.Asdescribedby

∗ Correspondingauthorat:DivisionofThoracicSurgery,DepartmentofMedical andSurgicalSciencesforChildrenandAdults,UniversityHospitalofModena,Via LargodelPozzon.71,41124Modena,Italy.

E-mailaddresses:beatrice.aramini@unimore.it

(B.Aramini),uliano.morandi@unimore.it

(U.Morandi),giorgio.desantis@unimore.it(G.DeSantis),brugioni.lucio@aou.mo.it

(L.Brugioni),alessandro.stefani@unimore.it(A.Stefani),ciro.ruggiero@unimore.it

(C.Ruggiero),alessio.baccarani@unimore.it(A.Baccarani).

manyauthors[1–3],metalsupportsforinternalfixationtostabilize thesternuminthenewcorrectedpositionareusedatour institu-tion.ThemodifiedRavitchprocedureisaveryinvasivetechnique, butitisstillthebestsolutionincasesofseveredeformityofthe sternum.

Infectionsofthewoundarenotveryfrequent;however,itisvery dangeroustokeepthebarsinsideincasesofwoundinfectiondue totheriskofseverecomplications,suchasboneinfection.Inthe scientificliterature,thevacuum-assistedclosure(VAC)procedure isawell-definedtechniqueusedincaseswithsuspicionofwound infectionbecausetheaspirationservestokeepthewoundclean [4,5].However,webelievethatitisnotsufficienttoavoidinfection, especiallyregardingthesternum.Inthiscasereport,the impor-tanceofperformingsurgicaldebridementmultipletimesincases ofwoundinfectionafteramodifiedRavitchprocedureforpectus https://doi.org/10.1016/j.ijscr.2019.12.023

2210-2612/©2019TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons. org/licenses/by/4.0/).

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B.Araminietal./InternationalJournalofSurgeryCaseReports66(2020)322–325 323

Fig.1.A.Patientsbeforesurgery.1B.Pectusdeformityisclearlyvisibleinsupinepositionaswellasbychestx-ray.1C.Chestx-rayaftersurgeryandbeforebarsremoval, showingasatisfactoryresultwithnohardwareexposure.1D.Thewoundbeforethefirst-timesurgicaldebridement.1E.Thewoundappearsredandfullofserum.1F-G.The debridementandmedicationduringthesecondsurgicaldebridement.1H.Thirdtimesurgicaldebridement.1I.Thewoundappearedlessredandwithoutserum.Atthistime theskinwasclosedafter10daysofVACtherapy.

excavatumhasbeenemphasizedbecausethesurgeondecidednot toremovethebars.VACtherapyisimportanttoperformassoonas theclinicalconditionhasbeenstabilized;however,itisnotenough topreventinfection.Webelievethatpectoralismuscleflap trans-position[6–9]wasthecorrectapproachcombinedwithmultiple debridementsandVACtherapytotreatthispatientwithoutthe necessitytoremovethebars.

Thefinalresultsafteroneyearweregoodintermsofboth aes-theticskinclosure and patientsatisfaction.Thiswork hasbeen reportedinlinewiththeSCAREcriteria[10].

2. Casepresentation

A24-year-oldmaleunderwentamodifiedRavitchprocedurefor pectusexcavatumforapersistentreferredtachycardiaanddyspnea onexertion(Fig.1A,B).PreoperativechestCTshowedasevere pec-tusexcavatumwithHallerindexequalto3.44.Forthefirsttime,the pectoralismuscleflapmobilizationadaptedtothemodifiedRavitch techniqueforpectusexcavatumreconstructionhasbeenshown withnocomplications.Afterbeingdischargedontheeighth post-operativeday,thepatientreturnedtoourhospitalduetoexcessive

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Fig.2. Pectoralismusclemobilizationandsuture.

serum exitingfrom thesurgical wound.A clinical examination showedthatthehardwarewasexposed.Microbiologicalsamples fromthewoundwerenegative,andthepatientwasapyretic,with nogeneralsymptoms.Therapywithabroad-spectrumantibiotic wasintroduced.Inaccordancewiththeplasticsurgeon,thepatient underwentsurgicaldebridementmultipletimes(threetimes)to preventinfectionofthebone(Fig.1D–H).VACtherapywas per-formedeverytimeafterdebridement.Thepatientwasthenreferred tothePlastic SurgeryUnit.Thefinal closure ofthewoundwas performed10daysafterthelastdebridement.

Atthis time,a pectoralismuscle flaptransposition was per-formedtoreducetheriskofinfection,protectingthebarwiththe musclelayer.Bothpectoralismuscleswerecarefullydissectedon asuperficialprefascialplanefromtheoverlyingskinand subcu-taneouslayer.Whenproceedingcranially,carewastakennotto devascularizetheskinflap.Thepectoralismuscleswereelevated, and the thoracoacromial pedicle was identified and preserved. Muscleswerethenmobilized asneededtoreacha comfortable lateral-to-medialrotation/transposition.Oncetheflapshadbeen fully mobilized, hemostasis was accurately controlled, and the twoflapsweresuturedtooneanothermediallywithPDSsutures (Fig. 2). Withthis, full muscular coverage of the osteotomized sternumand ribswas obtained.The hardware wasalsoalmost fullyprotectedbythismaneuver.Twosubmusculardrainswere inserted,andthemusclesweresuturedinferiorlytothedeepfascia ortotherectusmusclefasciatoobtaincompletemuscular cover-ageofalltheunderlyingelements.Finalclosurewasthusobtained withskinsuturesinadoublelayer(Fig.3).

Thepatient wasdischarged in good conditionafter 10 days withnofurthercomplications.Atonemonthaftersurgery,an out-growthfromthewoundappearedatthelevelofthesternumwith thereleaseofclearserum,whichwasnegativeon microbiologi-calexaminationandrequiredremovalundergeneralanesthesia afterpatienthospitalization(Fig.1I).Theone-yearfollow-up exam-inationshowednomorecomplicationsandtotalresolutionofthe surgicalscars.ChestX-rayshowedradiologicalfindingsindicating completestability,withnohardwareexposure(Fig.1C).

3. Discussionandconclusion

Sternochondroplastyisastandardprocedureforthecorrection ofpectusexcavatumdeformity[1–3]. AlthoughnowadaysNuss minimalinvasiveprocedureisconsideredthestandardprocedure inmanycenters,thescientificliteratureunderlinesthevalueof themodifiedRavitchproceduretoreducetherisk of

complica-Fig.3.Finalclosureafterpectoralismusclemobilization.

tionsaftersurgery[11,12]. Infact, in2016Kanagaratnam etal. in a systematic review and meta-analysis suggested no differ-encesbetweenNussandRavitchproceduresforpediatricpatients, althoughinadultstheRavitchprocedureresultedinfewer com-plications [11,12]. For this reason, the open approach and the pectoralismuscletranspositionhavebeenchosen.

Woundcomplicationsinthepresenceofhardwaremaybe dev-astatingfunctionally,aesthetically,andpsychologicallygiventhe highexpectationsofthepatient.Salvageproceduresareindicated onlyincasesofnegativeserummicrobiologicalcultures,nofever, andnoclinicalcomplications.Ifthepatientbecomespyreticwith apositiveresultforbacterialinfectionatthelevelofthesurgical wound,thebarsmustberemovedimmediatelytopreventsevere infection.Inourcase,we optedfora salvageapproach withan accurateclinicalassessmentofthepatientassociatedwith mul-tipledebridementsessionsintheoperativeroomundergeneral anesthesia.

Performing debridement multiple times is a very important solutionandVACtherapymayimprovethepossibilityofsaving thehardware,thuspreservingthesternuminthecorrected posi-tion[4–6].However,thisapproachmaynotbeenoughinthecase ofdehiscenceofthewound.Toavoidinfectionandremovalofthe bar,weshowedinpracticeforthefirsttimetheutilityofusingthe pectoralisflapmobilization,whichguaranteesabettercoverageof thebarsassociatedwithagoodaestheticalresult,especiallyinthe caseofthinpatients[7].

Infact,thisapproachallowsforasignificantimprovementof thefinaloutcomebyprovidingawell-vascularizedlayerprotecting hardware,supportingboneandcartilagehealing,andimproving softtissuethickness.Furthermorebutlessimportantly, vascular-izedmusclerepresentsanidealsiteforadiposecellgraftremoval incaseofneed.Furtherstudieswillneedtobeundertakentoshow therealeffectandbenefitsofthisnewsurgicalapproach.

Sourcesoffunding

Nofunding.

Authorcontribution

ABandBAwrotethecasereport.GDS,LB,AS,CRandUMrevised thecasereport.

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B.Araminietal./InternationalJournalofSurgeryCaseReports66(2020)322–325 325

Researchstudies

EthicalBoardapprovalisnotrequiredforcasereportsinour Center.

Declarations

Availabilityofsupportingdata:yes.

Ethicsapprovalandconsenttoparticipate

EthicalBoardapprovalisnotrequiredforcasereportsinour Center.

Consentforpublication

Consentforpublication:writteninformedconsentwasobtained fromthepatientforthepublicationofthiscasereportandforany images.Acopyofthewrittenconsentisavailableforreviewbythe Editor-in-Chiefofthisjournalonrequest.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed

DeclarationofCompetingInterest

TheAuthorshavenofinancialandpersonalrelationshipsto dis-close.

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