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Background
Congenital absence of the midline sternum is a rare chest wall anomaly that exposes mediastinal structures and causes paradoxical respiration, leading to respiratory and feeding difficulties. This report describes the successful surgical management of an infant with complete absence of the midline sternum using a chondral flap technique to restore stable native tissue coverage.
Case Description
A 2-month-old infant (birth weight 3.2 kg) presented with flail chest movement and a swelling over the lower neck that increased during crying. A computed tomography (CT) scan confirmed the absence of sternal ossification centers, with a defect measuring approximately 6 cm on ventilation and 4 cm during spontaneous inspiration.
Surgical Technique
Surgical repair was performed at two months of age. Following skin incision, subcutaneous flaps were elevated to the level of the nipples to ensure adequate exposure. The strap muscles and the sternal attachments of the sternocleidomastoid muscles were carefully released. Bilateral pectoralis major muscle flaps were then mobilized to provide a well-vascularized soft tissue coverage and protection of the reconstruction.
A laterally based perichondrial flap was fashioned to achieve robust approximation of the sternal borders. The bilateral pleural cavities were opened, and a thymectomy was performed to increase intrathoracic space and alleviate potential mediastinal compression. Sliding chondroplasty was subsequently performed using oblique incisions in the costal cartilages, enhancing chest wall compliance and facilitating midline approximation.
Outcome
A transient rise in central venous pressure (CVP) and airway pressure was observed and subsequently normalized. The patient was extubated on postoperative day two. Transient diaphragmatic palsy resolved without intervention. Oral feeding was established, and the patient was discharged on postoperative day seven.
Discussion
Congenital sternal defects are rare, and the surgeons’ experience with this reconstructive approach remains limited. Early surgical intervention is generally recommended due to the high compliance of the neonatal thoracic cage.
Several alternative reconstructive techniques have been described. Autologous rib grafting enables the reconstruction of the anterior chest wall by bridging the midline defect with costal segments, providing satisfactory rigidity and cardiac protection. Fibular bone grafts, whether vascularized or nonvascularized, offer a more robust structural substitute and can be used as longitudinal struts in cases of extensive sternal absence; however, they are associated with increased morbidity. Prosthetic materials, such as PTFE patches, represent another alternative, particularly when autologous tissue is insufficient.
Conclusion
Chondral flap repair is an effective reconstructive option that allows for tension-free closure using native tissues, with favorable early outcomes.
References
- Santoki N, Negi S, Kumari S, Bhatia A, Kumar R. Congenital Absence of Sternum: A Surgical Technique for Successful Outcome. Cureus. 16(2):e54488. doi:10.7759/cureus.54488
- Hinchcliff KM, Xue Y, Wong GB. Reconstruction of Congenital Sternal Cleft: A Systematic Review of the Literature. Annals of Plastic Surgery. 2021;86(5S):S418. doi:10.1097/SAP.0000000000002724
- Nooreyazdan S, Das B, Kaul S, Singh J, Parmar V. Surgical reconstruction for absence of sternum and pericardium in a newborn. Indian journal of pediatrics. 2006;73:367-368. doi:10.1007/BF02825837
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