A novel technique for the reconstruction of resected sternoclavicular joints: A case report with a review of the literature
This is a 52-year-old female patient who underwent sub-total thyroidectomy with a preoperative diagnosis of multinodular goiter; however, the postoperative pathology findings revealed a papillary thyroid cancer.\nTwo months after her surgery, she noticed a swelling just below the original collar incision which was hard in consistency and rapidly increasing in size. The swelling was located at the level of the manubrium, with a conspicuous erythema on the overlying skin. The rest of her examination was unremarkable.\nA CT scan of the chest was performed and showed extensive bone destruction of the manubrium that is causing mild compression of the innominate vein []. Tc-99m bones scan showed intense activity at the manubrium coinciding with the CT findings, with no uptake elsewhere in the body. Work up for distal metastasis was negative.\nWith these findings, direct invasion of the manubrium from residual retrosternal thyroid tumor was suspected and this was confirmed by fine needle aspiration biopsy from this swelling which showed papillary thyroid cancer; however, the patient was scheduled for en-block resection of the residual tumor. The surgery stared with a vertical sternal midline incision meeting the previous collar incision at the middle which was also opened over the previous scar, then both pectoralis major muscles flaps created bilaterally by undermining the medial border of the muscles. The internal mammary arteries were ligated bilaterally and the manubrium was excised at the level of first and second ribs on both sides together with the medial thirds of the clavicles [Figure , ]. Bilateral neck dissection was performed through her new midline and previous collar incisions. For the reconstruction we placed a dual-layer Proceed mesh on the mediastinal surface that was sutured to underlying tissue with prolene 2.0 sutures, overlying the mesh, two pieces of titanium bars and clips with 45° angles placed at the clavicles and crossing in an X fashion connected to the 2nd ribs bilaterally. The clips were fixed in place using special pliers provided with the STRATOS system []. Two drains were left overlying the mediastinum; a second Proceed mesh was used and was placed between underlying bars and soft tissue. Closure of the defect was achieved with the pectoral flap and the overlying soft tissue.\nPostoperatively, recovery was uneventful, the patient discharged one week after the surgery in a very good condition. The histopathology report of the specimens revealed a differentiated papillary thyroid carcinoma involving the manubrium with five positive lymph nodes: Two located in the central pre-tracheal area, two in the superior mediastinal beside the innominate vein, and one lymph node adjacent to the right internal jugular vein. However, the surgical resection margins were clear. She was referred to the oncologist and he advised for postoperative ablation treatment in the form of high dose of radioactive iodine.\nThe functional results are excellent with the patient being able to perform all her daily activities unassisted one month after the procedure. The patient was followed up 8 weeks after the procedure for functional scoring of her shoulders, scoring was performed by an independent party for both active and passive range of motion as well as power testing of the shoulder muscles, and achieved almost complete range of motion, and with functionally acceptable limitations in power [].