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J Thorac Cardiovasc Surg 1998;115:466-467
© 1998 Mosby, Inc.

BRIEF COMMUNICATIONS

Heterotopic ossification in pedicled intercostal muscle flaps causingclinical problems

Rupert Prommegger, MD, Georg Michael Salzer, MD


Innsbruck, Austria

From the Department of Thoracic Surgery, University ofInnsbruck, Innsbruck, Austria.

Received for publication August 26, 1997 Accepted for publication Sept. 3, 1997. Address for reprints: Georg M. Salzer, MD, Department of ThoracicSurgery, University Hospital of Innsbruck, Anichstraße 35, 6020 Innsbruck,Austria.

The pedicled intercostal muscle flap is often recommended in thoracicsurgery for prevention of bronchopleural fistula after pulmonary resection orreconstruction of the airways, because of its known potential forneovascularization and its general availability in the thoracic cavity. Apartfrom skeletal muscle, the pedicled intercostal muscle flap contains vessels,nerves, and more or less periosteum of the adjacent ribs including pluripotentmesenchymal cells that can develop to osteoprogenitor cells, so thatossification of the muscle flap may take place. The potential of this flap todevelop heterotopic ossification, which is to be distinguished from ectopiccalcification, was observed in experimentalGo 1and clinical studies,Go 2 but arestriction of its use by this peculiarity has never been reported in theliterature. This is the first report to demonstrate that unpredictableheterotopic ossification in the pedicled intercostal muscle flap occasionallymay cause severe clinical problems.

PATIENT 1. A 35-year-old woman with extensive adenoid cystic carcinoma ofthe distal trachea and carinal region had carinal resection and right upperlobectomy, followed by reconstruction of the bifurcation. A pedicled intercostalmuscle flap was wrapped around the trachea–right bronchial anastomosis toreinforce it. After a 11/2-year uneventful postoperative course, thepatient began to have dyspnea and repeated episodes of bronchitis and mucusretentions in the right bronchial system. She also had pain in the right dorsalhemithorax. Stenosis of the entrance into the right intermediate bronchus,caused by an ossification reaching from the neck of the sixth rib to the dorsalside of the trachea–right bronchial anastomosis, was diagnosed (Fig. 1). The ossified parts of the muscle flapwere excised. Histologic examination showed lamellar bone with mature bonemarrow. The patient recovered to complete health. She has no symptoms and isfree of tumor 7 years after the primary operation.



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  		Fig. 1. Thearrow shows the ossified pedicled intercostalmuscle flap reaching from the neck of the rib to the bronchus intermedius(asterisk) in patient 1.

 
PATIENT 2. A 39-year-old patient had extended adenoid cystic carcinoma ofthe distal trachea and carinal region. Bifurcational resection andreconstruction of the carinal region were performed. Seven days after theoperation a bronchoscopic examination showed mucosal paleness in the rightmain-stem bronchus, indicating reduced perfusion in the right half of theanastomosis. To provoke neoangiogenesis in the endangered airway section, weprepared two intercostal muscle flaps and wrapped them around the right part ofthe anastomosis. This method was not successful, and secondary rightpneumonectomy was performed. The muscular wrap around the right main-stembronchus was resected, but the major parts of the pedicled intercostal muscleflap remained at the medial wall of the left main-stem bronchus. Simultaneously,the trachea–left bronchial suture line was covered with newly preparedomentum majus. The patient did well for 6 years until increasing intrathoracicpain and dyspnea occurred. Malacia of the left main-stem bronchus was diagnosed.Repeated stenting was necessary, and 1 year later a bronchoesophageal fistula atthe distal end of the endobronchial uncoated wall stent developed. Computedtomographic scanning showed multiple ossifications of the remaining parts of themuscle flap (Fig. 2), reaching to the immediate neighborhood of the fistula. These ossifications fixed the esophagusto the stented left main-stem bronchus, possibly favoring development of thefistula. At right rethoracotomy, the fistula was divided and the esophagealdefect sewn up. Because the bronchial opening was not occluded primarily, andbecause the omentum had been used 6 years earlier, a pedicled anddeepithelialized fasciocutaneous flap from the anterior thoracic wall, which hadbeen precut 2 weeks before the operation, was interposed to occlude thebronchial leak and reinforce the bronchial wall. This method was not successfuland the patient died of mediastinitis.



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  		Fig. 2. The multipleossifications, as well as the wall stent (arrows),are shown. Note the spaces inside the bone, imaging bone marrow in the ossifiedpedicled intercostal muscle flap in patient 2.

 
PATIENT 3. A 37-year-old hitherto healthy woman had the acute onset ofsevere retrosternal pain. A 9 to 6 cm infracarinal bronchogenic cyst withcompression of both main-stem bronchi and compression of the right pulmonaryartery, which was nearly occluded, was diagnosed. Because the wall of the cystwas fixed extremely close to the stem of the right pulmonary artery, the cystcould not be excised completely. The epithelium was shaved off from theremaining part of the cyst wall, and a pedicled intercostal muscle flap was sewnto the inner side of the wall remnants to prevent recurrent cyst growth. After 1symptom-free year she is again having increasingly deep intrathoracic pain,caused by ossification of the muscle flap. Resection of the ossified muscle flapis planned.

The pedicled intercostal muscle flap contains muscle, artery, nerve, andalso periosteum of oneGo 2 or tworibs.Go Go 3,4Ossification of the muscle flap is a well-known phenomenon.Go Go Go 1,2,4 In their pioneering experimentalwork in dogs, Fell and associatesGo 1showed that extensive ossification of the flaps occurred in every case if theperiosteum adhering to the flap was not treated with 20% silver nitrate.The logical consequence to avoid ossification of the muscle flap would be toprepare the flap free of all periosteum, but this will result in reducedstability of the flap by frying of the short muscle fibers, endangering theunderlying intercostal vessels. The excellent results of Rendina and associatesGo 2 in 56 patients prompted us to askwhether the preparation technique of these authors, including the periosteum ofonly one rib in the muscle flap, is superior to ours,Go 3 which always includes the periosteumof two neighboring ribs. Today this question cannot be answered. We had threeossification-related complications in 22 patients who were treated with apedicled intercostal muscle flap. Also unclear is the value of the clinical useof silver nitrate,Go 1diphosphonates, indomethacin (INN: indometacin), or mild irradiationGo 5 for minimizing the occurrence ofneoossification of pedicled intercostal muscle flaps in patients. From theclinical point of view, it is hard to relinquish the pedicled intercostal muscleflap, because it is easy and quick to prepare, it allows either a posterior oranterior pedicle to be prepared, and it can reach all the important points inthe thoracic cavity.

In the future it will be necessary to gather more data about thefrequency, exact localization, and time course of ossification of the muscleflap, which can be gained only by thorough radiologic follow-up of patients.Such a base will open the search for techniques to avoid undesirable changes ina very useful aid in thoracic surgery.

References

  1. Fell SC, Mollenkopf FP, Montefusco CM,Mitsudo S, Kamholz S, Goldsmith J, et al. Revascularization of ischemicbronchial anastomoses by an intercostal pedicle flap. J Thorac CardiovascSurg 1985;90:172-8.[Abstract]
  2. Rendina EA, Venuta F, Ricci P, Fadda GF,Bognono DA, Ricci C, et al. Protection and revascularization of bronchialanastomoses by the intercostal pedicle flap. J Thorac Cardiovasc Surg 1994;107:1251-4.[Abstract/Free Full Text]
  3. Putz R, Salzer GM. Lunge. In: Kremer K,Lierse W, Platzer W, Schreiber HW, Weller S, editors. ChirurgischeOperationslehre. Spezielle Anatomie, Indikationen, Technik, Komplikationen.Erste Auflage. New York: Georg Thieme Verlag; 1991. p. 281-2.
  4. Papp C, McCraw JB, Arnold PG. Experimentalreconstruction of the trachea with autogenous materials. J ThoracCardiovasc Surg 1985;90:13-20.[Abstract]
  5. Myers MA, Minton JP. Heterotopic ossificationwithin the small bowel mesentery. Arch Surg 1989;124:982-3.[Abstract/Free Full Text]



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