OSTEOPLASTIC THORACOPLASTYthe rib bed. Figs. 1 and2 showthe outlines and the modeof formation of the flap. The extrapleural plane is entered below and the lung is then freed downwards

Thorax (1955), 10, 1.

OSTEOPLASTIC THORACOPLASTYBY

SIR RUSSELL BROCKFrom Guy's Hospital and the Brompton Hospital, London

(RECEIVED FOR PUBLICATION JANUARY 26, 1955)

During the past eight years (since March, 1947)I have been using a modified thoracoplasty whichhas stood the test of time sufficiently to justifypublication. I had had the operation in mind forseveral years before this but had not had thecourage to use it, for the actual step of cutting anosteoplastic flap from the ribs and sewing it overthe mobilized lung to hold it down was ratherintimidating. However, the difficulties encounteredhave not been great and the results have beenencouraging.

ADVANTAGES CLAIMED FOR THE OPERATIONThere are certain objections to thoracoplasty in

its various standard forms, whether it is used asdirect treatment for pulmonary tuberculosis, orwhether it is used to supplement lung resection.The objections are chiefly related to the actual

removal of ribs, with the attendant deformity, theneed for multiple stages, and the extra danger,especially in poor-risk cases, of paradoxicalrespiration after operation when the support ofthe ribs is lost. Although the deformity can belessened by careful physical treatment so as to bealmost imperceptible, it may be very noticeable,especially from the cervico-thoracic scoliosis androtation of the head and neck; this is an importantdrawback in thinly covered women, and particu-larly so in young women.A chronic fibrocavernous lung lesion with tough

extrafascial adhesions and contracted overlyingribs, if a collapse procedure is needed, usuallyrequires one of the standard forms of thoraco-plasty, preferably with the Semb apicolysis. Thereare, however, other cases with less disease inwhich a lesser procedure may be possible.Mobilization of the lung can be achieved byextrapleural, or part extrapleural and part extra-fascial, apicolysis, and the lung can then be helddown by an osteoplastic flap consisting of segmentsof the third and fourth ribs. The lung is givenimmediate support and there is no risk of para-doxical respiration. As the only alteration of thethoracic cage is displacement of the segment of

A

the third and fourth ribs, there is no external de-formity; the conservation of the first two ribs isespecially valuable, as it avoids an ugly depressionbelow the clavicle and also prevents the disfiguringcervico-thoracic scoliosis.

In an attempt to overcome the disadvantages ofordinary thoracoplasty a number of surgeons havereintroduced the principle of the insertion of aplombe of foreign material between the ribs andthe lung after it has been mobilized. The avail-ability of modern plastic substances has encouragedthese attempts in the belief that the body is moretolerant of them than it was of paraffin wax or" gomenol " and olive oil in the days when thesewere popular. Time alone will tell how long thepresence of such foreign materials will be toleratedby the body. Fundamentally the surgeon shouldbe uneasy about their use and their presence inthe body, even though the new plastics may seemto be better tolerated.The osteoplastic thoracoplasty described here

aims at giving an equal degree of collapse withimmediate stability and without the dangers anddisadvantages of introducing foreign substances;the collapse is achieved by a simple displacementof the living tissues of the body.Some other surgeons have used various osteo-

plastic modifications of thoracoplasty (Eloesser,1942; Overholt and Kenney, 1951; Bjork, 1954),but none uses a comparable osteoplastic flap.

SELECrION OF CASES FOR OPERATIONThe present success of lung resection in all its

forms for pulmonary tuberculosis has led to farfewer collapse operations being done, except assupplementary to resection. Osteoplastic thoraco-plasty should be considered in any case in whichpermanent and selective collapse of a resistantupper-lobe lesion is needed, especially when theavoidance of deformity is important. As alreadystated, it is best not used when the upper lobe iscontracted, fibrous, and with densely thickenedpleural and extrafascial planes; nor is it indicatedfor collapse of the whole lung. Where a space-

on August 18, 2021 by guest. P

rotected by copyright.http://thorax.bm

j.com/

Thorax: first published as 10.1136/thx.10.1.1 on 1 M

arch 1955. Dow

nloaded from

http://thorax.bmj.com/

SIR RUSSELL BROCK

reducing procedure is needed after resection, osteo-plastic thoracoplasty supplies this need excellently,as will be shown later. In fact its use in con-junction with resection has proved to be perhapsits most important application since the declinein favour of the pure collapse procedures. I have

I:C -..- 4-/'

FIG. 1.-The ribs have been exposed and the mode of cutting the osteoplasi

very high at the back. The musculoplastic modi-fication already described (Brock, 1946) may beused with advantage. It is better not to incise anintercostal space but to strip the periosteum fromthe upper border of the fifth rib and the lowerborder of the second rib. The intercostal bundles

are thus stronger and their bloodsupply less liable to be interferedwith, and the extrapleural layer canbe easily entered by incising throughthe rib bed. Figs. 1 and 2 show theoutlines and the mode of formationof the flap.The extrapleural plane is entered

below and the lung is then freeddownwards to the level of the sixthrib or interspace and upwards tothe second rib or first interspace; atthe same time commensurate free-ing will be done, behind into theparavertebral groove and well for-wards in front. As soon as theunder surface of the third and fourthribs has been freed it is an advan-tage to make drill holes and dividethe ribs. The drill holes are simplyand conveniently made by an instru-

,tic flap is outlined. ment shown in Fig. 3 and specially

also used it in a case which hadbeen unsuccessfully treated by aplombage with plastic spheres andin which secondary lobectomy wasneeded.

THE OPERATION

The principle of the operation isto perform the correct amount ofextrapleural or extrafascial pneu-monolysis (or a combination ofboth) and then hold the lung inthe collapsed position by an osteo-plastic flap composed of segmentsof the third and fourth ribs, withthe intercostal muscles, vessels, andnerves preserved intact in front andbehind so that the nutrition of theflap is unimpaired. The cut endsof the ribs in the flap are sewnbehind to the anterior longitudinalligament of the spine and in frontto the rib cartilages.The incision is the usual J-shaped

posterior one for thoracoplasty ex-cept that it need not be carried

.,

FiG. 2.-The flap has been cut and its construction can be appreciated. It Qonsists ofsegmentsof the third and fourth ribs with the second, third, and fourth intercostal bundlesconserved intact both in front and behind. In this way nutrition of the flap is unimpaired.Note drill holes in ribs.

2



j.com/


arch 1955. Dow

nloaded from


OSTEOPLASTIC THORACOPLASTY

made for me. This instrument has been used forsome four years and has proved very useful.

Posteriorly the ribs are divided just in front ofthe angle; anteriorly about the mid-axilla. After

FIG. 3.-Rib drill (Genito-Urinary Manufacturing Company).

a little practice the necessary length can readilybe estimated; it is usually about 6 in. (15 cm.). Ifany doubt is felt about the site of anterior division,this can be deferred until after the lung has beenfreed and the exact distance measured from thespine to the costal cartilages. Once the ribs havebeen divided and the upper boundary of the flapdefined by incising the periosteum in the lowerpart of the bed of the second rib, an excellent ex-posure of the interior of the chest is obtained,and the pneumonolysis can be completed with easein the usual manner.The flap is not yet sufficiently mobile to reach

the lung in its collapsed position, but can easily bemade so by freeing the periosteum, and hence theintercostal bundles, right back to the head of theribs and a short distance in front. Judicious extratouches and freeing here and there will give full

mobility to the flap. As the rib segments mustrotate medially as well as be displaced medially,it is necessary to incise the periosteal beds of thetwo divided ribs in the gaps in front and behindto allow the ends to rotate. If the stripping is donewith due care the vessels and nerves in the inter-costal bundles remain intact.The flap must now be fixed in position. The

posterior ends are sutured to the anterior longi-tudinal ligament; this is easily exposed by verylittle dissection, though care is needed to avoidpuncturing the near-by veins. The third rib is fixedabout 1.5-2 cm. below the azygos arch, the fourtha short distance lower (Figs. 4 and 5). On the leftside the fixation is made just above the aortic arch.I used to use stainless steel wire for the sutures(as indeed can be seen from the radiograph, Fig.12), but I now use strong linen thread (No. 25).If the anterior longitudinal ligament is picked upboldly and cleanly by the needle a very strongfixation is secured. It is better to pass the stitchesthrough the drill holes in the ribs and then to leavethem untied until the anterior stitches are in place.This part of the operation will be found difficultwith an ordinary needle, but is easy if a Harris'sboomerang needle is used. The upper stitch ispassed round the third cartilage just lateral to theinternal mammary vessels and then through thedrill hole in the third rib. The suture for the fourthrib is placed round the fourth costal cartilage.Sometimes the anterior end of the fourth rib canbe left free.

Fio. 5

FIGS. 4 and 5.-The mediastinal exposure after pneumonolysis and the mode of suture of the back ends of the ribs to the anteriorlongitudinal ligament of the spine.

3



j.com/


arch 1955. Dow

nloaded from


4

Once all the sutureshave been inserted a finalcheck is made of the dis-position of the flap and theintercostal bundles (whichshould be quite free), be-fore the sutures are tied.The flap will now be foundto be firmly fixed, holdingthe mobilized lung downto the level of the hilum.The curve of the ribs re-produces the natural shapeof the upper part of thenormal thoracic cage, andit is almost as if a newbony apex has beenfashioned to accommo-date the upper lobe atits new level. This iswell shown in the variousradiographs.The gap between the

lower edge of the flapand the chest wall shouldnow be loosely closed byinserting a few mattress

FPo. 7

SIR RUSSELL BROCK

FIG. 6.-The flap in place in coronal section.Note apposition of flap to mediastinumabove, and how the gap between the flapand the chest wall is supported below bymattress sutures.

.._

:.

....

.2_i,:

*_E..:_b.1_.*:

...._ .i.

..

.....',

.Z_ffi.

.a__

...,.w_s_fle

.:

.s*.s.s??_

.......in_J

sutures from the fourthintercostal bundle (i.e., thelower fringe of the flap) tothe fifth intercostal space(Fig. 6). Sometimes itmay be necessary to placea stitch or two above,between the second inter-costal bundle (which formsthe upper fringe of theflap) and the mediastinum,but usually this gap isclosed by simple apposi-tion of the flap to themediastinum.The wound is closed

without drainage, unless,of course, a lung resectionhas been done.

In some of the earliercases in which the lunglesion was more exten-sive and extended lowenough down to demanda seven- or eight-ribthoracoplasty, the mobi-lization was extended

FIG. 8

FiGs. 7 and 8.-Radiographs of a case in which extra collapse was obtained by extending the extrafascial and extraperiosteal mobiliz-ation downwards, the lower ribs (6, 7, and 8) being left in place.

: 1.I

-I. ;-.1 -j;I ,

I ." 6

I :

t I:

::

...... :I",,%*:..



j.com/


arch 1955. Dow

nloaded from


OSTEOPLASTIC THORACOPLASTY

FIo. 11

FIG. 9

,...@...............

:::

..

FIG. 12

FIGS. It and 12.-The earlier type of operation in which a three-rib flap was used. Note also the use of stainless steel wiresutures. Note the absence of spinal deformitv.

FIG. 10

FIGS. 9 and 10.-Radiographs of two-stage-osteoplastic thoraco-plasty. In such a case some thoracic scoliosis is inevitable.

I

5

:E

L-

Awk- -VAL



j.com/


arch 1955. Dow

nloaded from


SIR RUSSELL BROCK

further down. This was achieved by stripping thesixth and seventh and, if necessary, the eighth ribsand mobilizing the intercostal bundles right backto the heads of the ribs so that a musculo-periostealflap was formed and sank in (Figs. 7 and 8). Thismay be attached on a deeper plane by a few in-terrupted sutures. If necessary it can be performedas a second stage; indeed, a second osteoplasticflap may be cut and sewn in place in a mannersimilar to the first flap if so wished (Figs. 9 and10).

In the first case in which the operation was useda two-rib flap was cut, but the tissues were thin andthe intercostal bundles were damaged, so thatnecrosis occurred and the flap had to be removedand a formal thoracoplasty substituted. After thisthree ribs (third, fourth, and fifth) were used so asto make a more stable flap, and there was nofurther trouble with nutrition (Figs. 11 and 12).However, the three-rib flap is not necessary andmoreover may be a disadvantage in that a shortscapula may just catch on the edge of the sixth rib.For some time now I have reverted to the originaltwo-rib flap with complete satisfaction.

DISCUSSION AND RESULTS

When used as a supplement to lung resection theoperation can be begun in a similar way by strip-ping the periosteum from the top border of the

fifth rib and incising through the rib bed; divisionof the back end of the fifth rib will then allow theribs to spread to give adequate exposure for re-section. When the rib spreader is used care shouldbe taken to evert the fifth intercostal bundle so thatthe vessels and nerves are not bruised. After thelung resection the flap is cut exactly as describedand sewn in place. This gives a very satisfactoryreduction of the hemithorax with immediatestability and support of the lung. The end-resultcan be seen in the radiograph in Fig. 13, in whicha right upper lobectomy and resection of the apicalsegment of the lower lobe had been done.

It will be seen from the various radiographs thatthe mobilization and collapse of the lung is main-tained absolutely and to a degree no less than isachieved by thoracoplasty. If relaxation andcollapse are to secure healing of a lung lesion thisshould be attained by the operation. Indeed,collapse may easily be made too great, especiallyin front, where it should be remembered that theflap is fixed to the costal cartilages. It is to gradeoff the amount of anterior collapse that the lowerrib is left free in front; the amount of anteriorcollapse can be further lessened by suturing theanterior ends of the ribs not so far medially asthe costal cartilages.

Osteoplastic thoracoplasty has been used in 25cases and the results are tabulated on page 8.

FiG. 13.-Osteoplastic thoracoplasty complementary to right upper Fio. 14.-Radiograph of bilateral osteoplastic thoracoplasty. Beforelobectomy and resection of apical segment of lower lobe. the operation a huge cavity was present at each apex.

6



j.com/


arch 1955. Dow

nloaded from


7OSTEOPLASTIC THORACOPLASTY

FIG. 15 FIG. 16

FIGS. 15 and 16.-After bilateral osteoplastic thoracoplasty, to show absence of external deformity.

FIG. 17 FIG. 18

FIGS. 17 and 18.-Radiographs before and after operation in which the present two-rib flap has been used. No wire sutures. Noteabsence of deformity.

II§i. .l



j.com/


arch 1955. Dow

nloaded from


SIR RUSSELL BROCK

RESULTS IN 25 CASES*Total ... ... ...

Died ... ...

Failed ... ...

Good result ... ...

Combined with resection ...

Bilateral ... ...

*Longest follow-up is 8 years.

25 cases161861

It will be observed that only one death occurred,and this was in an unfit woman aged 54 who alsohad a right upper lobectomy. In one patient theoperation was used on both sides (Figs. 14-16);this patient originally had a large cavity in bothupper lobes and was a very bad risk; the right sidewas operated on in May, 1947, nearly eight years

ago, and the left side in October, 1947, seven anda half years ago. She remains well and does allher own housework and ordinarily has no coughor sputum, though occasionally she produces a

trace of sputum, which has been positive at times.In six cases the operation has been combined

with lung resection and has given complete satis-faction except in the one death.

In six cases it failed, and the patient has eitherbeen left alone or a secondary resection has beendone. The failures were really due to faultyselection in the first instance, although this wasperhaps excusable because they were all casescarrying a very bad risk in whom it had been

hoped to gain control of the disease by a lesserprocedure than formal thoracoplasty.

In 18 cases (including five resections) theresults have been good and have remained good.A very gratifying thing has been the excellentcosmetic result. This is well shown in thebilateral case (Figs. 15 and 16). Of these 18patients four have been followed up for over sevenyears, three for over five years, six for over fouryears, three for two years, and two for between18 months and two years. Certainly thereseems no reason to expect any complication fromthe use of the osteoplastic flap itself. Figs. 17 and18 show the appearance before and four yearsafter operation in which a two-rib flap was used.Many surgeons would to-day treat a case of thistype with resection, but even then a space-reducingprocedure might well have been needed.

I should perhaps explain that the reason the totalnumber of cases in which I have used the pro-cedure is so small is chiefly because of the greatchange that has occurred in my thoracic surgicalwork during the last few years.

REFERENCES

Bjork, V. 0. (1954). J. thorac. Surg., 28, 194.Brock, R. C. (1946). Ibid., 16, 182.Eloesser, L. (1942). Amer. Rev. Tuberc., 45, 703.Overholt, R. H., and Kenney, L. J. (1951). Surgical Forum. Clinical

Congress, American College of Surgeons, 1950, p. 3. Saunders,Philadelphia.

8



j.com/


arch 1955. Dow

nloaded from


Documents

OSTEOPLASTIC THORACOPLASTYthe rib bed. Figs. 1 and2 showthe outlines and the modeof formation of the flap. The extrapleural plane is entered below and the lung is then freed downwards