Pectus - Surgical Approaches for Failed Repair

Well, I guess at this point we're gonna move into more of the, the surgical approach and uh I, we kind of touched on this a little bit. We were gonna talk just a little bit about how young is too young, so we probably may not need to even touch on this again, but this was a patient, the 5-year-old male with Marfan's disease and had a CT of his chest at 22 months of age. Had a Haller index of 4.65 with a mild mass effect on the right atrium and ventricle and then uh got a cardiac MRI at 4.5 years, Haller index of 36, leftward cardiac displacement, aortic root dilatation, and, uh, because he was uh symptomatic, I guess this is a picture of the patient, uh, Doctor Garcia operated on him. Here's his uh cardiac MRI. And uh. Underwent the nest procedure, uh, no stabilizers, um, and, um, the bars were secured with PBS. So that was just an example, and we already kind of talked about, you know, the 4 year old that presents like this, so we can go ahead and go into your presentation, Don, if you want to. Sure. So, um, the, you know, you guys had asked me to talk a little bit about redo surgery and, um, I, I, about 30% of my practice is revisions and they're not all mine. I, I do a lot, a lot of things, but I certainly learned a lot from every case and so, um, you know, if you can go to the next slide. If you look at recurrence risk, and that's what all the patients ask me, um, you know, it, it, it varies in what's reported and, um, you know, some sites report almost, almost no recurrence to um a fairly high rate. And you know, I would imagine that the true incidence is really unknown and um many patients don't report back to centers and I think, I, I know that um when I did the original adult open a paper with Funkels at UCLA. We had like a 5% um reported rate and over the last um 10 years of my career, I'd say I've had at least 20 patients from that series contact me and wanna be revised cause they've recurred. So, so I think we don't really know how high recurrence can be. But um there's certain things that, you know, increase the risk and on your next slide, If you, if you look at revision cases, they're very different reasons that they recur from a NUS versus a ravage or similar type open. And, you know, your NUS patients are gonna be more related to technical issues, bar positioning, bar rotation, um, and then pulling them out too early. Whereas, when you get to your open cases, um, they can be very complicated with, you know, issues from healing, malunion. Um, the regression itself is a very different beast, and so I thought we'd just look at some of those cases. So on the next slide, just looking at nus alone. Um, you know, your issues are gonna be, you know, bar. The bar rotated, the bar, um, was not placed exactly right so that it was, you know, not positioning up. It stripped laterally so then it regressed backwards, um, you know, you pulled your bars out early cause the patient had pain or otherwise, or then you kinda get into this complex group of connective tissue disorders where, you know, things just don't stay like they're supposed to and uh how long do you actually pull those bars out. Um, on the next slide, your rotation, I just put a couple of photographs and X-rays of different bar rotations, and, you know, in all of these, once the bars rotate, their ability to put pressure and elevate the chest wall is, is not there, and usually they cause pain too. On, and on the next slide, when you look at probably the most common thing that I see in the adults is the lateral stripping. So, if you look at the X-ray from the front, the bar looks perfect. But if you look from a side view, the bar has stripped posteriorly. And on the next slide, I'll show you the CT scans that correspond with these X-rays. And you can see, you know, the bar is inside the chest. So, once it's not supported by the intercostal space and posteriorly migrate. It's, you, you have no forward um elevation and, and worse, you, a lot of times you can have cardiac um obstruction or, you know, obstruction down on the lobars into the diaphragm and the liver. And then the, the next slide shows from inside the chest, what, what it looks like. So, on the left is a bar that, you know, it, it's not chest touching the, the center of the chest or the sternum at all, so it's not elevating. And on the right is one that I pulled out that is not touching and it's compressing actually the diaphragm and causing issues. So, why, why are these, you know, things fell? Well, a lot of reasons, um, in the adult population, it's also, often because the chest is so stiff and rigid that the inner spaces can't support the pressure of the bar, so they rip out and they, you know, they, they, they spread wider and they, you know, they, they drop the bar in. Um, pressure also makes it easier for the bars to rotate, so you get a lot of rotation. Um, it can be, you know, I, I, I, I'm a big believer in using more bars on adults and balancing pressure. And, and on the next slide, um, I listed just some of the things that I do that um I, I think are helpful. I use forced sternal elevation, which I'll, I'll show you some examples of. Um, I reinforced the inner spaces on uh some of the, the, the heavier adults and um I used to only reinforce spaces that kind of stripped when I put the bars in and now I've gotten to wearing these bigger guys, um, if, if I think there's any chance at all that those bars are gonna strip laterally, I'll reinforce and I'll show you that. Um, I fixed the bars medial, use multiple bars, and, you know, if, if I'm not able to get them to elevate properly, you know, I've gone to, you know, doing a little bit of a releasing osteotomy. So the next slide shows the rule track, which is, it's basically a retractor we use to hold the chest up when we do the internal mammary for um heart bypass. And we, we, we just put a basic um bone clamp on there into the sternum and attach it to it. And it lifts and elevates this so that when you're rotating your bars and, and dissecting through, you don't have the um force. And on the next slide, it shows you, um this is a thoracoscopic view, so I'm looking from the side. You can see on the left, the big hump, the defect, and then with the elevation on the right. You've got this nice open space that you can dissect through and pass your bars and stuff. So for me, um, it, it's interesting, for the first year, I was only using it on complicated cases and then I, I, I, I, I was like, why am I not using it on all my cases cause it makes it easier. So I pretty much use it on, on everybody now just for safety and ease of the procedure. The reinforcement, you can see, this is a bar that's kinda stripped and I, I use the fiber wire, which is a woven um PTFE product, um, suture, and I basically just do a figure of eight around the ribs and the bar so that those, the, the ribs can't separate open and allow the bar to drop in and, and strip further on the inner space. That's just kinda a drawing of what that looks like. And then we talked about I use multiple bars. So, um, balance defect, you know, the initial, uh, teaching and the way I started doing it was, you know, single bar in the center of the defect. For the, for the heavier, stiffer chest, you know, that, that is not enough and it's fir first of all, tremendously painful to have that much pressure on a bar, but, you know, from a risk of movement and stripping, if you balance out the defect, it does very well. So, about 30% of my patients now, I'll do 3 bars. Um, and then on the next side, um, I use fiber wire, not the stabilizers, and kind of catch at least 3 ribs and on some of the lower bars, now, if I put a very low bar, I'll actually make a little incision over the sternum and take a drill and I'll drill a hole through and pass the suture and loop around the, the, the sternum and the bar in the center to make 100% sure that these bars don't rotate. Um, just a few case examples of showing, um, these are all revisions that I've done. This is a 28-year-old kid. Uh, he had a NU performed two years ago, severe pain, um, still residual defect. His hallar was 46. You can see, um, the little inset, his stabilizer is completely, uh, palpable at the, the back aspect. The bar from the lateral view is rotated, so it's, you know, the defect is below the bar. So, my thoughts on this kid, um, if you can show the next slide, uh, looking at his scans and stuff for revision is he was extremely stiff, um, for a 20 year old, um, not much movement. Uh, the, the single bar had failed to lift him and rotated. Um, they had used a really long bar and the, you know, the stabilizer was lateral, so it, it wasn't even um supporting or stabilizing the bar. And you know, from inside on a CT you can see that the majority of his defect is low, it's below where his bar is placed. So on him, we, um, we, we pulled out the 17-inch bars. Um, I used the rule track to pop him up. Um, I reinforced his inner spaces to make sure that they didn't, um, strip out, given how stressed, you know, how tight he was. And we put 2 14-inch bars which corrected him, you know, quite nicely. The next case, um, 20-year-old, so a little bit younger, he had had a surgery with a single bar placed, and then, um, about six months later, they went back and put in a second bar. Uh, it still failed to elevate him, and now he developed, um, kind of this carinatum on the left side. It severe chronic pain, uh, it's on the right and, um, you know, kind of this residual, you can see the scan below the bars. He's got this, um, all right, actually, that's in between the bars, but he's got this big carinatum, um, defect now. So, on him, you know, my, my thoughts were, well, OK, the, once they kind of developed that asymmetry, sometimes it can be hard to get that down. But, but on, on physical exam, it was pretty compressible. So once I pulled the bar out, I could actually um depress um just with my fingers, the caratum. So, we, we went ahead and um On the next slide, we, we pulled out the, the 2 15-inch bars that he had and put him up on the rule track, and the defect popped up really nicely. He still had a little bit of residual caratum, but I, and I was able to compress it. So my, my thoughts were he could either brace or I could see if I could tie that down to a bar. And um once I put the 2 12.5 inch bars, you can see on the next slide. There, there was a, right above that bar um was where the car aum was and I put a couple of sutures around and it pulled down really nicely to the bar and um correct, corrected him quite nicely. Um, that was the correction, sorry, it's in the previous slide, but you can see. Um, this is an interesting case. 49-year-old woman who had, um, two prior attempts. Uh, she'd been to the OR 3 times, two prior attempts and, um, a, um, A bleed in the chest that required re-operation, severe pain. Um, her residual hallar was 4.9. She had cardiac compression from the bar which you could see on echocardiogram and on her CT scan, you can see her bar has, um, migrated, you know, intrathoracic and lateral and below that bar, she's still got quite a bit of, um, defect. On the next one, it'll show her X-rays, um, You know, after her first surgery, this is her X-ray, and, and they had put two bars in and the bars are on top of each other, and when you see that with two interspaces, you know that those bars, at least one of them has stripped out that they're able to be on top of each other. So they, they took the one bar out and they went back in and put a second bar in. Um, they put stabilizers on both sides this time. But you can see on the lateral that um the bar has again migrated and stripped posteriorly so that it's, you know, not supporting the chest. So, in her case, you know, um, our thoughts were, you know, she's already had two surgeries, um, which were complicated. She was in the hospital for like a month and, um, Uh, you know, it's gonna be a complicated, and, and these are one of the cases where you say, well, you know, maybe she needs, you know, some sort of osteotomy, some sort of partial open procedure. And we decided to, you know, see what, what we could do with the rule track and um uh you guys were there for this wonderful case that I think we spent about 4 hours just getting adhesions down in her chest with a camera. Uh, very stuck, pericardium stuck. She'd had pericarditis, she'd had effusion, a lot of issues. And, but once we got her adhesions, we were able to put a roll track on and get her lifted. And so with, once, once you kinda get them lifted, then you're, you, you're probably gonna be successful. Um, I did reinforce her inner spaces. Um, and so on the next slide, you can see, she, um she got two bars and um she elevated pretty nicely. I don't have it, these are immediately post-op. I don't have updated photos, so she's still quite swollen and, and, um, and, uh, scarred down, but she turned out very nicely and um has had uh A lot of, a lot of follow-up in New York where she's from that's, um, that, that she's doing quite well and quite happy. So those are just a couple of examples of where I think the forced sternal elevation helps with the stiffer chest and reinforcement, um, and kinda using multiple bars to, to support. So I don't know if you wanna talk about that or if you wanna talk about how I do my um kinda adult basic repairs, not redos. Well, I will tell you, since we, uh, came to Mayo and, and, uh, watched you and went to the Phoenix course and everything, I mean, I've used the railway tractor on almost all the cases. I just find it makes it so much easier and you just get across that plain, uh, so much easier and you feel safer and you just see the other side so much better. So that's been a great, uh, tool, I think for, um, for our repairs. I don't know, do you agree or? Oh, I agree. No, I mean, I think it's um a number of adjuncts that you've shared with us, uh, Don, uh, we, we've incorporated into our. Uh, into, into our practice, um, if I could ask a couple of questions, um. So you, several of the patients that you mentioned or that you just presented, the bars seemed to me were too long. Uh, what, what, what criteria do you use as far as the length of bar? Is it what Donald suggests as far as the mid axillary line? Is it the anterior axillary line? Is it, uh, That's a good question. It's a that is a moving target. OK, so, so, um, you know. Too long is a problem. And when we started doing the cases, um, we figured that out very early, especially in the stiffer chest, that, you know, your fulcrum of movement, the further back your stabilizer and the further back the end of your bars and you're securing them, the more unstable they are immediately. So, we went through a phase where, um, you know, I kind of copied what Hans Pellegaard was doing and we're doing them really short. And then um I had it, I had to take a couple of those out that fell in the inner spaces into the chest and I decided that was too short. So, I kind of, uh, you know, I'm kind of 2 to 3 centimeters over, overlapped and Um, you know, I use that measure and every patient's shape is different. So some of them, um, you know, they, they kinda have a square side of the chest. Some of them are rounded. And what I wanna make sure is that the, that bar is kinda catching one of those side ribs, but not wrapping all the way around to the back. And, um, You know, I, I do it different on every patient with measuring and kind of feeling where that's gonna lay. And it's much harder on women because of the breast tissue or, or heavier guys cause you can't get a nice good feel of it. But, you know, I, I try to do, um, you know, you, you kind of see it on the X-rays I've shown, just a little bit, 2 or 3 centimeters at the most around the curve of the side and, and not much longer than that. How about you guys? Yeah, so, uh, you know, it, it seems to me that if you're going to be able to get stitch, uh, sutures around 3 different places on, uh, for each bar around the rib, uh, you're not gonna be able to do that if you have a really sharp bar. Uh, but then on the other hand, uh, if we're sort of exploring doing children, and it's one thing I don't know if you've been able to visit parks. But I would imagine that when he uses the short bar, which he advocates, uh, that it's, he's not putting sutures around 33 different spots around, around the bar rib complex, uh, so it, uh, as you say, it's a moving target. It depends on the morphology of, of, of each individual patient. The, the other question I wanted to ask you, is that how do you determine, um, you know, how much rigidity is too much rigidity and then that you need to do some relaxing incisions. So I'll, I'll actually, um, let me talk about that in the next little segment because I, I've got some pictures and stuff. OK. Right. Uh, OK. Can you see the slides going? Yes, are we moving on? No, I can't see the slides. Are we moving on? Yeah, we'll move on. Yes, OK, actually, I guess, well, I, I didn't, I was trying to find a good time. There was a question about um if you could discuss the osteotomies. Yeah, so, yeah, let me do that in the next section. I'm going to do that in just one minute. Can we back up one slide? Sure. So, um, let me just talk about, um, the, the osteotomy and stiffness. So, I just finished going through my, um, looking at, you know, 30 and older versus 18 to 29 patients. And, you know, we looked at over 300 adults that we've done over the last few years, and, and I, I don't remember the exact exact number, but over 2 of them, 200 of them are, are over the age 30. And so we broke, broke those patients down into cohorts to try to look at, you know, the older versus the younger adults. And in that younger group under 30, almost all of them, there was only a couple that I couldn't get to lift with using the rule track and, and, you know, forcing them up with that Lorenz dissector. Um, in the older group, it was still a reasonable amount. It was like 88.7%. I could do, but that 1211, 12% just would not lift. And so, on the next slide, you know, I put a clamp on them and I attach them to the rule track. And I took a picture of this because um the OR staff is, you know, rolling their eyes at me because, you know, this is my 3rd clamp on, on this guy, which um I keep trying to elevate him and the clamps, the clamps keep breaking. And um he actually popped up at that last clamp and so I was trying to prove a point that, you know, my tenacity won. But, but a lot of the patients, you know, they just don't lift. And you can, you can make the decision, well, you wanna try to put the um The, the Lorenz dissector in and try to see it with that little bit of extra that you can force it. And sometimes if you, if you go high a little bit above the defect, you can get it to lift with that dissector and you can kind of slowly work your way down. But, you know, if they're not lifting, um, the, the kind of the most common thing I see are patients with bars in them that didn't lift and they will say, well, you just need to keep the bars in longer and they'll lift eventually. If they don't lift, they're not, the bars are not gonna make them lift. They're not, they're, they're not strong enough to do that. So, I'll do a little incision and um It's kind of, I, I, it's like a little mini um osteotomy and it, it's usually pretty clear where it's not lifting up. And I'll start by just making cuts, uh, you know, and just, just freeing the cartilages from the sternum at that site. It'll come up then and then you've got to Just like the old fashioned rabbit, you've got to, to address and kind of shorten those cartilages to get them to come back down. And sometimes you need to, I don't know if you can see my hand, but you know, you've cut them here at the sternum, you've got to do a kind of a second releasing cut here. But it's, it's, it's the exact same procedure is kind of the cartilage sparing ravage where you're just taking a little segment out. You're not taking extended. And then I'll often actually put a little plate, um, if it's trying to lift up at all and some of these guys, I'll put a small plate across. But on the next side, you can see, um, you know, this is a guy, uh, very severe defect, bodybuilder, it's just, just, I mean, completely rigid chest and um On him, I, I, I wasn't gonna give up, so I actually attached two clamps in separate areas and lifted him, um, and all I managed, all I managed to do was snap his sternum in half by trying to elevate him. So, I mean, he, he clearly needs to be cut and so, you do a small midline incision. You know, I finished the sternal osteotomy. I, I, you know, clean those edges off. He had um a couple of cartilages on the side that I needed to release and then he came up very nicely and, you know, a nice repair. Um, on the next slide, uh, this is a an older gentleman. You know, round severe defect. But surprisingly, um, he, he lifted all except for one little lower left rib cartilage that was stuck. So I made a little small incision over that and, and sliced that rib, and he came up right up. Um, so it's, it's amazing. It's sometimes it's uh, um, only one or two sites that are fixing. So you don't have to do this big conversion on everybody and open them up. So, I try to do, um, what I call a hybrid repair. So I'll, once I get them up, I'll put bars in them just like a regular NUS patient. And, and these, these are two examples of, um, you know, where I plaited areas that were, yeah, I found cosmetically, in the, in the beginning, I wasn't plaiting them. I was Just putting like a um uh a bike roll or, you know, suture in like I, I would have done the old fashioned ravage. But I found that a lot of times they, they'll kind of knob up and not look as cosmetically nice. So now I, I'll put a little plate to stabilize them and, and they, they heal very nicely. So that's kind of, that's my cutting scenario. So did, did you wanna talk ever talk about like the uh the unstable like chest wall and. You know, we've had a couple of patients that have had that after ravages, right, um, so, one of the things that we've seen, and I know that I think I sent you one of our patients, one of the patients, not my patient, but a patient that was referred to me, and that is that that defect in the chest wall. Yes, I got some great slides of that. Uh, can you spend how much? Well, let's, let's, uh, well, let's see. Well, it depends on, so we have, uh, we have about a half an hour left still in this session, but, uh, I, there was just a couple of questions about the whole removing the cartilages. Um, are you using the terms osteotomy and disconnecting the cartilages interchangeably? Um, yes. So, I try, you know, the, the kind of the old, um, old teaching of, you know, it's cartilage sparing where you, you know, you sheath out the, um, uh, you know, the outside and, you know, preserve the perichondrium and just, you know, take the segments out. When you, especially in these older patients with calcified, you get in there and it's all stuck and it's a big mess and you, you, often you can't do that nice, beautiful, um, procedure that we always did in the teenagers. So, what I've ended up doing is, is, you know, starting with just a sliding, slicing osteotomy and freeing the rib or freeing the cartilage off the sternum. And then, when the sternum's up, when you go to try to bring that back, it's often redundant, and you can't bring it back and flat. So then I'll take a little segment out. To make it so that it'll approximate nicely. So, so it's, I mean, you, you, if, if they have nice preserved um perichondrium, I'll, I'll try to, to sheath that out and, and do kind of the, you know, the cartilage sparing procedure, but it's often, you know, just kind of what won't lift is a mash of cart, you know, calcified um cartilage that, that you can't do that nice um clean procedure. And so when, what instrument are you using to, to do this thoracoscopically? Um, so you're not, so if you have to cut, you have to do that open. So Patricio Varela little incision. Have you, have you ever Patricio Varela, he's in Santiago, Chile, presents removing the cartilages thoracoscopically, and I don't, I don't remember if he uses just cautery. I don't remember how he comes through it, similar to the rons that the spine surgeons use for doing discectomies. Anterior release. So we work a lot with our, our, our spine surgeons and uh do the exposure and so there's a thoscopically, right, thoroscopically, right. So wrong draws, and you can use the wrong draw then to go ahead and take a wedge out of the, the, the cartilage. OK, OK, yeah, um, so there's, there's that. It seems like a lot of work, but it's, uh, is it not? Is it pretty easy to do? Well, I, I don't, I, my sense is that it's not as precise as just making an incision, just doing it there. And then the other thing is, is that if the, if, if it's rigid, uh, you're gonna want to have that incision anyway, uh, in order to go ahead and put your plate, which, which is something that I think Dawn can can comment on. Uh, but Don, the other thing is, what I'd be interested in knowing what your approach is for horns of steer, you know, we have that combination carronadum and, and sort of excavatum. What, what do you do for that? Um, and I'm gonna sort of frame it by saying that, you know, one of the reasons why the NUS procedure, I think, has supplanted the ravage is that you preserve that inherent elasticity of the chest wall. And one of the reasons why we've embraced the bracing procedure for caringotom as opposed to the ravage procedure for the caronotom is is that again, we found that it to be quite effective if the child comes at an early enough age and we avoid that Ravage procedure, which really compromises their chest wall function and elasticity in later years. So your thoughts, no, I definitely agree, um, you know. I only cut if I have to and um you know, I, I have um I have in one or two patients um just use my bowrie cautery to cut. You know, and just split a little bit if I've needed to. But most of the time, if, if it's that simple. They just lift it anyway. Um, it's kind of the, the really more complex calcified and, you know, sometimes I, generally, I use just an osteotome to open, but sometimes the, it, it's I mean, it's bone and you, I have to get actually a little mini sternal saw and saw through it. So trying to do that thoracoscopically um is possible, but, but very difficult and The biggest issue is, you know, you gotta stabilize that somehow. So you either need a stitch to approximate and hold it together or you need a plate. You need something cause otherwise, that, that rib is not gonna stay down. It's gonna, it's gonna elevate and stick up because you just changed all the alignment of the chest and it, it's not gonna lay nicely and, and be fine. So, um, you know, I, I, I, I've Fiddle a lot with, you know, the same thing with the carronad. I was trying to do them from the inside, minimally invasive and stuff, and cosmetically, I just didn't end up with good results that, you know, now, a small incision, I can, you know, do, do a lot through and it turns out very nicely. Um, Go ahead. So I was gonna suggest that within the remaining 20 minutes that we might touch on the, um, a couple of patients that, yeah, well, the ravage, but a couple of patients that I have referred from a, a colleague, uh, adult colleague, uh, in Alabama who was putting in biosorb and resecting out cartilages and then leaving patients with these huge defects in the chest wall. Uh, but then also want to sort of, uh, morph into the on cue pump, your experience with the on cue pump. Central is here, uh, to my left. Um, I'll let him introduce himself and it's time for him to give his comments, but I, I thought we would take advantage of one just, uh, maybe a couple of minutes about talking about what your approach is for those defects a couple of slides there, um, to one more there. So, so the redo opens, um, those, those. are like big categories. They're, they're the ones that, you know, they didn't get support. They just fell in. You can, you can re-nest them. They, they lift really nicely. Um, they're the ones that are kind of fixed that are gonna require osteotomies, and then they're the, the ones that you're talking about, the big disasters with holes in their chest and malunion. And on the next slide, you know, we, we looked at a couple of 100 of our, our patients. If you can flip to the next slide, um, and, and kind of broke it down into an algorithm, you know, if they have any evidence of hernia, malunion, or their thoracic dystrophy, those patients are automatically open, uh, you know, you're gonna have to do them open. All the other ones will try to put the rule track on and, and do them just like I do primaries. If they lift, great, I put bars in, they don't lift, you know, I'll convert and do a small incision with some osteotomies. So, on the next slide, you know, this shows a, a, a guy that doesn't look like a really severe recurrence, but um he, he's very stiff and when I tried to lift him, he didn't lift. So I reopened that incision and I still use the rule track on these guys and I'll put the rule track on. I'll open up the little osteotomy sites that are, are holding things up and then I'll put the bars in and the Lorenz dissector just like that. And all of these guys I prep out with the groins exposed uh in case we get into uh life-threatening bleeding, I can go and bypass through the groin. Um, when I've done with these, I do plates on all these patients. I put bars to support them posteriorly and I plate them anteriorly, and, um, you know, they didn't heal the first time and I, I learned early on of trying to redo some of these, um, with just bars and when I pulled the bars out, they, they recurred again. So I, I've become a big, big fan of anterior plating. The next case is um a, a guy who's 45. He had a, a RAAG done two years ago. His haler is now 8.3, which is um 2 points higher than it was before his surgery. So we went in on him, and he actually, uh, on the next slide. Elevated quite nicely. Um, he had one spot that, uh, was kind of fused abn abnormally, um, that we cut and put a plate on and then three bars. So he, he lifted very easily and, um, I didn't find any malunion otherwise on him, so he's a good one to just kind of small plate and, and lift with, you know, reasonable results. You go through their old scar, so you're not adding anything new. Um, malunion is kind of the big issue. So, here are just 3 CT scans where you can see, um, malunion or pseudoarthrosis, however you wanna call it, uh, worst-case scenario, floating sternum, but, but sometimes it's, you know, it's hard to, to completely assess by scan. You can do it better by physical exam, but, you know, you generally see these ribs that are, are not attached by, um, to their, their midline are the best clue. And then on the next, um, uh, this is inoperative, what you find on these patients, you can see that, you know, none of the cartilages um are attached to sternum on either of these patients. And then the next film is a little basic, a little video here where you can see, you know, um, that whole left side, you know, the sternum's floating with, with nothing, nothing attached. And you, you know, you have a, a lot of pain and inability to valsalva. Um, it can be deceptive because the Haller index on these guys can be almost normal, um, and they're complaining of all these symptoms and so, you know, uh, a lot, many of the patients have seen multiple physicians and been told they were fine and, you know, they have these issues. So, you know, when you start talking about reconstruct, you're gonna have to stabilize these guys. You often need to do some sort of um graft, bone graft or like a a methylmethacrylate filler to, to um fill spaces, um, mesh and otherwise, but definitely plating and stabilization. And I'll show you an example. Here's a 28-year-old that um had a ravage at age 15. He's had chronic chest pain since then. um, on exam. He's, you know, got pretty severe malunion. You can feel his, his whole chest wall is, you know, moving all over the place. When he coughs, you can see paradoxical movement. And on index is only 3.4, so he didn't, he doesn't come across super severe. And on his CT scan, um, you can see, uh, there's, you know, The ribs are not, not coming in to sternum, at least in the one imaging, and then maybe it's something but you don't really see bone. Um, it's kind of a difficult, but on physical exam, certainly malunion. An intraoperative, um, you know, he, his sternum is completely separate from both sides of his chest wall. So, in his case, um, two bars posteriorly to hold him and stabilize him anteriorly. And then, um, you kind of clean the edges so, so you get viable tissue to, to reapproximate, plate across. And then I, I, I've had to put a little piece of biologic mesh in the middle because he is um His pec muscles had atrophied and lateralized, so, so even with um complete mobilization, there's still a little segment in the middle that wouldn't cover the plates. And it's really important on these skinny guys that you cover, cover everything. So we put a little piece of biologic mesh that, you know, the muscle will grow into and uh prox and incorporate with. So then, then the post-op shot, shot, you know, Doesn't look much difference, but huge difference as far as how he can feel and function and exercise function. Um, the next group that's really complicated are these big chest wall hernias, and this is a 62-year-old guy. He, um, I don't know if you can see in that image, he actually has two pectus bars in. Uh, he had a prior ravage, um, with excision, and he has this big, uh, hole in the front part of his chest with two bars posteriorly. So, if you pull those bars out, you know, he's just gonna, um, collapse down. Here is interop. You can see, um, we actually did a, uh, he's super thin with no subcutaneous tissues across the front chest wall, um, and had, had a skin graft which you can't see, but we, we laparoscopically mobilized some omentum and pulled it through the diaphragm and you can see his defect. And on the next slide should be his uh inoperative video. Um, so you can see, uh, that big area of hernia above the heart. He's a big runner. He, um, every time he runs, he said he can see his heart falling out of his chest, so he, he really wants to get this corrected as well as get the, the support bars out. And so, in his case, what we did was um I, I used methylmethacrylate to fashion and recreate that lower part of the chest wall that had necrosed out. Um, I used plating to secure it to the chest wall and stabilize it, and then we brought that piece of momentum up and over to cover all that and he, he had a really nice results and Has, um, it's about a year and a half out now without any recurrence, and no symptoms and doing well, back to running marathons. And the last case, oh no, I, I second to last, um, this is, this is one of the cases that, um, Doctor Garcia is talking about, a 47-year-old woman who he, you know, who he referred to me. She had had uh Ravage done with the Bioridge plating about a year before, um, severe chronic pain, um, Haller index is 4. On her CT scans, you see kind of just this, um, inflammatory fibrous, um, mass of, of conglomeration. And then on the next photo intraoperative, you can see this, um, partially disintegrated, um, Uh, material that's behind the sternum, you know, in between the cartilages, you know, free edge with um malunion and, you know, nothing healed together and stabilized. So, for these guys, you gotta get all of that junk out and clear it and um debris back to viable tissue. So we ended up with um This is what bars in. You, you got a little bit of a space, not enough to do methylmethacrylate, so we, we did some um cadaveric bone grafting um in like a, a paste with biologic mesh to support. And then her lower costal cartilages were completely detached with quite a bit of a bridge, so, um, we pulled up and stabilized all that with um titanium plating which you can see on the next slide. So she's got bone graft filling in all the spaces. Um, she's pulled up and stabilized back together and then I put the posterior bars in to kinda support her as a scaffold, uh, for a couple of years to heal. I've not pulled all that out of her, so, uh, hopefully, she, she, she's healing OK when it comes out, but, you know, chronic pain is a big problem on these guys and, um, uh, and some of them, stabilizing, fixing fixes their pain and others, not, not necessarily, so. Um, my last case, another gentleman with chest wall hernia. Uh, interesting case, 50-year-old guy had a ravage with a revision case 3 years ago. He was a band member, played the trumpet, very active, um, and since his surgery has been on disability with chronic narcotic dependence, can't play his trumpet, can't, you know, can't do anything, so he can't breathe. And you, you had been to literally 10 different physicians that told him he was fine. Um, on his CT scan, his Hallar index on inspiration is actually 2.2, so they told him there's nothing wrong with him. But when you when you repeat his scan through the expiratory phase, his hallar increases to 5 and the whole side of his chest collapses down and he has this huge hole on the left side. Um, On the next film, you can see intraoperative, what we have. You've got lung lung herniating out through the chest wall, um, with basically recurrence and collapse of the right side with no support down into the pericardium. So for him, we um again use methylmethacrylate. Uh, there's a lot of substances you can use. You can use titanium mesh, you can use titanium plates, uh, they can actually prefab, you know, like uh, uh, uh, replacement part with the titanium. Um, and then I, uh, use the bars posteriorly and again plated, uh, to try to stabilize him a bit anteriorly. And he, he did very well, um, back to playing trumpet, back to his life. His bars are out. He, you know, he hasn't recurred. Um, he's about 2 years out from a removal of his, his stuff. I did leave the anterior plates in on him. But, you know, that, those are, those are just many examples of um you know, what you see with uh these open procedures and you, you gotta, you gotta address all the issues and, and they're all different and all very complex and You know, the, the, there, there is no way to get these patients back to normal and I think that's the most frustrating part with this population is, you know, they're, they're never completely happy cause they, they're never normal again and, um, you know, your, your, your best with for them is to make them better. Don, how many revisions is too many? Well, I think it depends on what what they've had done. So, if you, when I see a revision that um is, that had bars placed and then they pulled the bars out and they collapsed, you know, you know that there's other issues that have to be addressed. Um, if they've had bars plating a million procedures and um are still collapsing. At some point, you're like, well, what are you gonna do to, to stabilize this person with a connective tissue disorder or, or a chest that just won't heal no matter what you do and then you start getting into infections, more osteonecrosis, and all these issues. And, and it's hard to know. Um, Doctor Sawyer and I have a, um, a joint patient that I think has been operated on 8 times, of which many of those are mine and so, You know, it's hard because you get into a cycle with these patients and they have one area that's a problem and you keep chasing, you know, chasing your tail on these patients and, um, you know, a lot of them are, are litiginous and it can become, you know, a big issue. So, Don, I mean, I think for me, for the audience, I, I would sort of reiterate, um, you know, 111 thing that comes to mind, and that is. Uh, all the patients you mentioned chronic pain, uh, this last patient, uh, and we're gonna talk about how do we minimize narcotic dependency, but many of the patients have chronic pain that require, uh, you know, narcotics. To me, the message for the audience is, is that the best operation is the first operation, uh, that we do the correct operation. Uh, as simple as this operation is, it could be a little bit of a, uh, sort of a deception that anybody can do it. There is a significant learning curve, and, uh, Donald has, has, uh, emphasized that, and I don't think that it really has gotten the necessary, um, attention, uh, that this is not see one, do one, and then, you know, that's, that's it. Uh, but pain is a, a big issue, and, um, uh, 11 of the reasons we, we asked, uh, you and one of the things that we took away from our experience with you is, uh, your rather ambitious bold goal of really minimizing the amount of pain these patients have not just, uh, initially in the hospital but throughout the hospital course.