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A B
Figure 26–3
Intraoperative diagrams, before (A) and after (B) dissection, of screw and hook placement and exposure of the ribs with rib-osteotomy
and placement of the ribs above the rod. (See Color Plates 26–3A,B.)
Distraction
rod
Rib osteotomy
A
Figure 26–4
Computed tomography of the apex of the curve pre- (A) and postoperative (B) showing reconstruction of the thoracic deformity.
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130
SECTION II THE THORACIC SPINE
Eurostile
Compression
rod
B
27
Convex Thoracoplasty
Randal R. Betz and Howard H. Steel
Goals of Surgical Treatment
Primary
1. To improve cosmesis
2. To decrease psychological effects
3. To improve the ability to sit in a chair
Secondary
1. To increase flexibility during surgical correction (a concave rib
osteotomy would probably also be required)
2. With rigid curves, the trunk does not always derotate despite current
advanced spinal instrumentation systems, and a thoracoplasty is an
excellent adjunctive procedure to posterior spinal fusion (PSF) or anterior instrumented procedure.
Diagnosis
1. Adolescents with thoracic and double major curves.
2. Patients with a thoracolumbar curve undergoing a posterior approach
may need to have the distal ribs resected.
3. Adult patients (쏜 21 years old) with rigid curves that will not derotate
following posterior instrumentation.
4. Patients with residual rib prominence following successful PSF who
complain of discomfort when they sit in a chair or lean against a wall.
5. Patients with psychological problems as a result of the deformity. A
psychological consult is recommended.
Indications for Surgery
1. A strong indication is a preoperative rib angle on radiograph or clinical
examination of 15 degrees or more.
2. Consideration is given when the rib angle on radiograph is greater than
10 degrees.
3. Curve severity greater than 60 degrees.
4. Curve flexibility less than 20 % on bending films.
5. Postoperative correction of the Cobb angle of less than 50% based on
an intraoperative radiograph.
Contraindications
1. Patients in whom pulmonary function may be compromised. A
decrease in pulmonary function is seen in the early postoperative period, which mandates proper patient selection. In one study (Lenke et
al, 1995), pulmonary function test (PFT) values declined an average of
16% at 3 months postsurgery in adolescents but returned to near normal at 2-year follow-up. The adults (쏜 30 years of age) experienced a
PFT decline averaging 27% at 3 months postsurgery, with a residual
decline averaging 23% at 2-year follow-up.
2. Thoracoplasty is not appropriate in patients with a severely rotated
spine when the ribs do not protrude beyond the posterior margin of the
spine. This can be assessed by a preoperative radiograph and computed tomography (CT) scan. Be aware that some patients with existing fusions complaining about the cosmesis are upset with trunk
asymmetry, which won’t be corrected by thoracoplasty. Careful assessment may indicate that an osteotomy of the previous fusion to bring
the apex of the curve closer to the midline should be combined with
thoracoplasty.
Advantages and Disadvantages
We use a midline incision instead of a two-incision technique because
with better translation of the apex of the curve to the midline, less rib needs
to be resected laterally than was necessary with a Harrington rod fusion.
With Harrington rod distraction for severe curves needing a rib resection,
the apex was minimally translated, and therefore most of the rib resection
occurred laterally. Most of the rib resection now takes place at the medialmost attachment in adolescents. In adults, more rib laterally may need to
be excised.
Procedure
Convex Thoracoplasty with Posterior Instrumented Correction of
Thoracic Adolescent Idiopathic Scoliosis
1. The patient is positioned as is standard for a PSF for idiopathic scoliosis.
2. The patient is draped from C7 to the midgluteal crease with wide margins posteriorly for adequate visualization of the rib prominence
(Fig. 27–1). The lateral drapes should lay at the posterolateral axillary
line, and wider if possible.
3. For a selected right thoracic fusion with thoracoplasty, it is necessary
to extend the skin incision distally to approximately L2 or L3 to retract
the thoracolumbar fascia adequately from the midline (Fig. 27–2).
Stopping the skin incision at T12 does not provide adequate lateral exposure for this single-incision technique. Likewise, proximally the
skin incision needs to be carried approximately 1/2 to one inch farther.
Despite the slight increase in length of the incision, it is still much
more cosmetically appealing than two incisions.
4. After skin incision, the spinous processes are outlined and the thoracolumbar fascia incised off the spinous process. In the L2-L3 region,
the surgeon must be careful to pick up the very thin layer of thoracolumbar fascia with forceps.
5. Using sharp and blunt dissection, this fascia is elevated off the paravertebral muscle fascia, developing a plane by working laterally and
proximally at the same time. The thoracolumbar fascia needs to be incised sequentially off the spinous processes as one proceeds proximally. This is a very easy and identifiable plane in a patient who has
not previously had a spinal fusion. It can be tedious and more complex
in revision spine surgery, but it can be done.
6. Once the fascia is retracted laterally, two Weitlaner self-retaining
spring retractors are used at top and bottom to hold it. The patient
should be told before surgery that some of the sensory nerves to the
skin do transfer across this area and will need to be incised during the
retraction.
7. The ribs are then palpated, starting at the apex of the deformity. The
most prominent are palpated first, and then, working symmetrically
(one distal, one proximal, two distal, two proximal), a symmetrical resection is made. The most important part of the procedure is deciding
how much rib deformity to resect. The philosophy to keep in mind is
that you can always take more rib out, but you can’t put it back. Taking
too much rib deformity and creating a concavity is worse than leaving
residual rib deformity. If the rib deformity is long and seven or more
ribs need to be resected, the patient should be told prior to surgery that
a second surgery may be necessary. Many factors are out of the surgeon’s control, such as the degree to which the rib compresses in when
it is cut. Some ribs are very rigid and continue to stick out, but upon resection others immediately lie down flat. For those that stick out, suturing them to the transverse process with a heavy nonabsorbable suture (No. 2) may be helpful.
8. Starting at the center of the deformity, the rib is marked with electrocautery and outlined. An Alexander elevator is used to pull the periosteum point off the surface of the rib to the lateral edge (Fig. 27–3).
9. Once the periosteum is stripped to the side of the rib, the opposite end
of the Alexander elevator is used to strip the periosteum and muscle
around the inferior edge of the rib.
10. Using a Cobb elevator, the remainder of the periosteum is stripped underneath the rib.
11. A Doyen elevator is passed circumferentially and pushed medial to
lateral on the exposed rib (Fig. 27–4).
12. Two right-angled retractors are placed on the medial aspect of the rib,
pulling back the paraspinal muscle. Using electrocautery and a Cobb
elevator, more periosteum is stripped until the medial-most attachment of the rib to the transverse process is identified.
13. A rib cutter is then passed around the rib and pushed as far medially as
possible, right up against the transverse process. The rib is grabbed
with a towel clip or a Kocher clamp to prevent it from plunging
through the pleura when it is cut.
14. The rib is then cut medially, with the plane of the cut as parallel to the
floor as possible.
15. The rib cutter is now moved so that it is at the lateral aspect of the rib.
For a standard rib resection with a 55-degree right thoracic curve, 2 cm
of rib should be cut for a start. This is where judgment again comes into
play, keeping in mind that it is easy to keep trimming more rib but impossible to put it back. Start with 2 cm and come back to that rib and
cut more if it appears necessary. Keep in mind that the apex of the
curve will translate to the midline of the spine, ultimately leaving a
Eurostile
27 CONVEX THORACOPLASTY
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B
A
Prosposed
resection for
moderate deformity
Convex rib 8
A
Paraspinal muscles
Pleura
Periosteum
B
Prosposed
resection for
rigid fixation
deformity
Spinous
process
Figure 27–1
Axial view of proposed resections.
7
8
Trapezius
9
Figure 27–2
Incision and retraction of the thoracolumbar fascia.
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132
SECTION II THE THORACIC SPINE
Eurostile
Blunt
dissection
L2
10
11
12
Thoracolumbar
fascia
Paravertebral muscle
and fascia
Muscle covering rib is
incised (elevator costarum m.)
Periosteum
Direction of pull
(Alexander elevator)
Alexander elevator strips periosteum and muscle
around inferior edge of rib
Figure 27–3
Incising the periosteum in the direction of the
rib.
Eurostile
Doyen
Lateral bone cut
(rib cutter)
Removed section sample (2 cm)Clamp
Figure 27–4
Stripping the periosteum circumferentially about the
affected ribs and removal of the ribs.
27 CONVEX THORACOPLASTY
133
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much larger gap than is apparent at the time of the rib resection. (This
does not apply when the spine is already fused and this is being done
as a secondary procedure, or if the procedure is done following insertion of the instrumentation.)
16. Bone wax is then applied to the ends of the rib, and Gelfoam is packed
into the periosteal bed to assist with hemostasis. Bone wax is used to
seal the ends of bone because of bleeding and to prevent air embolism;
it should be remembered that the rib regenerates through the periosteum and not from the ends of the bones, so the bone wax has no inhibitory effect on regeneration of the rib.
17. The additional ribs are then cut in identical fashion; generally, as one
goes proximally and distally, less rib is cut. For example, if 2 cm are
taken at the apex, then only 0.5 cm would be taken at the most proximal and distal ribs.
18. Once the entire resection has been completed, the operating room table
is rotated and the edges of the wound carefully lifted so that a small
pocket is created. Using a small pitcher (not the bulb syringe), saline is
poured into the wound carefully so as not to create any additional air
bubbles. The anesthesiologist does a Valsalva maneuver on the patient
three times to look for a leak in the pleura. (For what to do if a leak is
found, see Complications, below.)
19. A Hemovac drain is placed over the resected rib bed. It is important not
to suck on the pleura; a hole can easily be made by suction. Because of
pleural effusion being more of a risk with an increasing number of ribs
excised, the senior author (R.R.B.) currently uses a small chest tube (16
French) placed directly through the exposed pleura prophylactically
when six or more ribs are excised.
20. Using long-acting, absorbable suture, the thoracolumbar fascia is
closed with a running suture starting at the distal aspect of the wound.
It is necessary to close the fascia now so that debris from decortication
does not fall into the rib resection area and cause an inflammation. The
removed pieces of rib can then be cut into small pieces for use as autogenous graft in the spinal fusion.
Rib Resection During Anterior Instrumentation for Correction of
Thoracic Adolescent Idiopathic Scoliosis
Small pieces of rib are resected as posterior as possible in the intervening
ribs between the two intercostal space entrances and above and below. For
example, a piece of the ribs of T5, T6, T7, T8, and T9 approximately 2 cm
in length would be removed. If there is a very long rib deformity,then additional pieces of ribs can be removed, such as from T4 or T10. The instrumentation will have minimal effect on correcting the rib deformity, and the
rib resections will then facilitate mobilization of the chest wall to make the
discectomies and instrumentation easier to perform. The pieces of rib are
used for bone grafting.
Pitfalls
1. Following successful PSF with residual rib prominence, careful re-
assessment of the posterior trunk deformity with a rib prominence
radiograph and CT scan is essential. A rib deformity in a severely rotated spine may actually be caused by the most posterior bony elements of the spine, not the ribs.
2. Rib concavity from too much rib resection. Fortunately, with ex-
perience, rib concavity from excess resection rarely occurs. This complication must be prevented at the time of surgery. It is better to do too
little rib resection and come back later than to do too much. Eight or
nine ribs should be the maximum taken if resecting less than 2 cm. We
try not to resect more than 8 cm in length of any one rib.
3. Residual rib prominence, which occurs in two scenarios. In the first, a
long rib deformity exists, requiring resection of six, seven, or eight ribs,
and the risk of causing a rib concavity is high. In this situation, it is better to decide that a second procedure will be performed later. When the
original rib resection area is healing well, a subsequent rib resection is
planned for approximately 10 months later. This is really not a complication; it can usually be determined preoperatively and definitely intraoperatively, and the family and patient may be told ahead of time
that a second rib resection might be necessary. In the second scenario,
the medial portion of the ribs is prominent and the spine is severely rotated, so that a secondary procedure must be planned. We generally
wait 2 years after the original spinal fusion so that the convex rod can
be removed from the spine. At this point, the transverse process area of
the fusion and the entire medial portion of the rib down to the attachment of the vertebral body can be removed.
4. Prominent scapula. In our experience, the inferior medial portion of a
prominent scapula (up to 50 %) has been removed without causing any
functional deficits.
Complications
1. A hole in the pleura occurs during the rib resection in 5 % of patients.
It is extremely important not to attempt to repair the pleura itself. The
hole in the rib bed should be gently packed with Gelfoam and the intercostal muscle sewn in a running suture from the most medial to lateral
aspect. As the last sutures are tightened, the anesthesiologist expands
the patient’s lungs, expressing as much air from the pleural cavity as
possible, and the final sutures are tied. The purpose of closing the hole
is to prevent blood from seeping into the pleural cavity. An expanding
pneumothorax should not occur, as only the parietal pleura is violated
and usually not the visceral pleura. Hemovac drains are routinely
used. If there is a large hole in the pleura, insert a chest tube directly
through the hole and close the muscle around the tube.
2. Pleural effusion: On occasion, even without evidence of a pleural hole
at the time of surgery, a pleural effusion may develop, most commonly
when the patient has not worn a protective shell postoperatively. The
patient is observed with semi-erect and lateral decubitus radiographs.
For expanding, symptomatic effusion, a thoracentesis is performed
and, if it occurs a second time, a chest tube is inserted.
Postoperative Care
1. If a prophylactic chest tube is not used, a small protective shell is applied over the rib resection area following skin closure and dressing
application. This shell is essential. It helps avoid a postoperative flail
chest and, more importantly, minimizes motion of the cut ribs on top of
the pleura and prevents pleural effusion. The shell can be made of
plaster, with foam underneath to protect the skin. The mold is made
while the patient is prone on the table but is not applied until the
patient is in the recovery room, to prevent a severe plaster burn (which
the senior author has experienced in one case). After a chest radiograph is obtained to rule out pneumothorax and the shell has cooled, it
can be applied, wrapping it on with 6-inch Ace wraps. As an alternative, the posterior shell of a spinal orthosis that was custom made preoperatively can be recycled with Velcro straps and used postoperatively.
2. To determine long-term postoperative management, the patient’s back
is carefully examined 2 days after surgery. If no evidence of flail chest
is seen and the rib resection gap is thought to measure less than the
width of the palm of the hand, then no prolonged postoperative immobilization is needed. If a larger gap or a flail chest is seen, a postoperative rib protector (posterolateral half of a thoracolumbosacral orthosis)
is ordered. The rib protector, if prescribed, is worn for 3 months by adolescents and 6 months by adults, generally the amount of time needed
for the ribs to heal.
Suggested Readings
Betz RR, Steel HH. Thoracoplasty for rib deformity. In: Bradford DS, ed.
Master Techniques in Orthopaedic Surgery. Philadelphia: LippincottRaven; 1997:209–227.
Harvey CJ Jr, Betz RR, Clements DH, Huss GK, Clancy M. Are there indica-
tions for partial rib resection in patients with adolescent idiopathic
scoliosis treated with Cotrel-Dubousset instrumentation? Spine
1993;18:1593–1598.
Lenke LG, Bridwell KH, Blanke K, Baldus C. Analysis of pulmonary func-
tion and chest cage dimension changes after thoracoplasty in idiopathic scoliosis. Spine 1995;20:1343–1350.
Steel HH. Rib resection and spine fusion in correction of convex deformity
in scoliosis. J Bone Joint Surg Am 1983;65:920–925.
Thulbourne T, Gillespie R. The rib hump in idiopathic scoliosis: measure-
ment, analysis, and response to treatment. J Bone Joint Surg Br
1976;56:64–71.
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SECTION II THE THORACIC SPINE
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28
Anterior Thoracoplasty
Harry L. Shufflebarger
Goals of Surgical Treatment
1. Anterior thoracoplasty is partial multiple posterior rib resections from
within a thoracotomy. It is indicated in the surgical treatment of scoliosis when either an anterior procedure or a combination anterior/posterior procedure is performed.
2. The procedure includes excision of several rib heads, facilitating
access to the disc space.
3. Chest wall mobility is increased, facilitating intrathoracic exposure.
4. If a posterior instrumented fusion is to be performed following the
anterior, the ribs provide an excellent bone graft source.
5. Thoracoplasty improves the cosmetic result of the deformity surgery.
The surgical treatment of spinal deformity frequently includes an ante-
rior procedure. The anterior procedure may be thoracic or thoracoabdominal. In either instance, the goals are similar: correction of the spinal deformity and accomplishment of spinal arthrodesis. The cosmetic result of
the deformity surgery is considerably improved by the anterior thoracoplasty.
The purpose of the anterior surgery may include several items. The
anterior procedure may be a stand-alone procedure, with anterior instrumentation and fusion. The anterior procedure may be for release and fusion, preceding a posterior instrumented fusion.
The thoracotomy may be accomplished by removing one entire rib, or it
may be accomplished in the space between ribs. The anterior or internal
thoracoplasty follows. Several, usually three to five, posterior portions of
ribs are removed, including the heads of the ribs. This provides excellent
access to the disc space. In addition, partial removal of several ribs softens
the chest wall considerably, permitting greater exposure within the chest.
The rib portions removed may be morselized and used for graft in each interspace. In addition the ribs may be transferred to the posterior setup and
employed as graft for the posterior procedure.
Indications for Surgery
1. Anterior thoracoplasty is indicated whenever thoracotomy is indi-
cated in the surgical treatment of spinal deformity.
2. Several diagnostic categories require anterior surgery. Idiopathic
scoliosis (infantile, juvenile, adolescent, and adult) is the most common indication.
3. Anterior procedures may be required in idiopathic scoliosis in patients
with large curves to increase mobility, improve correction, and improve arthrodesis rate.
4. Prevention of the crankshaft phenomenon is another indication for
anterior surgery in idiopathic conditions.
5. Anterior surgery for nonidiopathic conditions is also frequently indi-
cated. This includes congenital and neuromuscular deformities, as
well as kyphotic deformities (e.g., Scheuermann’s kyphosis). In these
conditions, anterior thoracoplasty is useful for the several reasons
listed above.
6. Anterior thoracoplasty is a simple and valuable adjunct to anterior spi-
nal surgery. It should be considered in any patient undergoing a thoracotomy for spinal deformity surgery.
Contraindications
There are no contraindications. If the patient is suitable for thoracotomy,
the procedure should add no additional morbidity and little additional
time.
Advantages
1. Rib head excision provides wide access to each disc space, permitting
complete discectomy and division of the posterior longitudinal ligament if necessary.
2. If anterior instrumentation is to be done, screw placement is facili-
tated.
3. Excision of the posterior portions of several ribs permits much wider
exposure of the spine as rib spreading is much easier.
4. The softened chest wall is closed much more easily,never requiring rib
approximator instruments.
5. A large amount of autogenous bone graft is available from the resected
ribs. This may be used on the posterior procedure if planned.
6. Cosmetic improvement is enhanced by anterior thoracoplasty, as it is
by thoracoplasty accomplished from the posterior approach.
7. If a posterior procedure is planned for the same day, the large amount
of autogenous bone graft available negates the need for graft harvesting
during the posterior procedure.
8. If iliac graft is usually taken, there is no need for this.
9. If the surgeon employs posterior thoracoplasty, it has already been
done from the front, saving time on the posterior portion.
10. The amount of autogenous graft produced is particularly appealing in
neuromuscular conditions.
Disadvantages
The disadvantages are few:
1. Anterior thoracoplasty adds a few minutes to the operative time.
2. In my experience, the thoracotomy tube is usually left an extra day
when anterior thoracoplasty is done (3 days, compared to 2 days
without the procedure).
3. No instance of respiratory insufficiency has been induced by the thoracoplasty.
4. There have been no instances of flail chests.
Procedure
The technical portion of anterior thoracoplasty is relatively simple. The
thoracotomy is usually performed through the rib corresponding to the
most proximal vertebral level required for the anterior surgery, or one rib
distal to that vertebral level. The rib is excised completely, including the
rib head. The pleura is then incised. The ribs to be removed are all distal to
the level of the thoracotomy. The thoracoplasty is accomplished prior to
the spinal portion.
The parietal pleura is held with a hemostat. It is useful to place a rake
retractor on the chest wall muscles to provide traction. The pleura is then
peeled off of the chest wall. The index fingertip is a useful instrument for
this maneuver. With the pleura reflected, the posterior portions of the next
three or four ribs are visible. Electrocautery is used to incise the periosteum in the line of the rib. The intercostal muscles on the proximal and distal surfaces of the rib are dissected off of the rib with the electrocautery.Just
past the angle of the rib, a right angle hemostat is passed around the rib,
which is then divided with an end-on rib cutter. The cut end of the rib is
grasped with a Kocher clamp, and periosteal elevators and electrocautery
used to further strip the rib of muscular and ligamentous attachment. This
continues medially to the rib head, which is disarticulated from the costovertebral articulation.
After removal of the first posterior portion of the rib, the next several are
removed in a like manner. After completion of the rib resections, the rib
spreader is placed and the spinal portion of the procedure is performed.
After completion of the spinal portion of the surgery, routine closure of the
thoracotomy is easily accomplished. No special attention to the chest wall
is required. The thoracotomy tube is placed in the usual manner. Figure
28–1 illustrates the sequence of the procedure.
Several technical steps have evolved that simplify the procedure. Performing thoracoplasty prior to the spinal procedure is simple, and permits
wider exposure of the spine. Use of the rake retractor on the intercostal
muscle edge eases pleural dissection, and eases stripping of each rib. Passage of the right angle hemostat around the rib provides a safe environment
for the rib cutter. Both the electrocautery and a periosteal elevator are useful to disarticulate the rib.
Pitfalls
Pitfalls are few. There is the possibility of damage to the intercostal neurovascular bundle. This is most likely to occur when cutting the rib. The
method described above should avoid this potential complication. Careful
attention to hemostasis in the chest wall is necessary, and should decrease
the amount and duration of postsurgical bleeding from the chest wall.
There is some possibility of damaging the exiting nerve root with excision of the rib head. Rarely, a spinal fluid leak may be encountered with the
rib head excision. This indicates incidental durotomy of the dural sleeve of
the exiting root. It may also indicate damage to the exiting root. Control of
spinal fluid leakage may be difficult. Direct suture is usually not possible.
Packing the area with Gelfoam or application of fibrin glue has been sufficient to stop the leakage. Persistent spinal fluid leakage in the postsurgical
period has not been observed, though it is theoretically possible. It could
result in postural headache and persistent high-volume thoracotomy tube
Eurostile
28 ANTERIOR THORACOPLASTY
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Rib excision
A
Parietal pleura on chest wall
with hemostat
B
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136
Figure 28–1
The sequence of anterior thoracoplasty. (A) The rib excision with thoracotomy. (B)
The parietal pleura on the chest wall held with a hemostat.
SECTION II THE THORACIC SPINE
Eurostile
Pleura reflected and
Posterior portions of ribs excised
posterior ribs exposed
C
Figure 28–1 (continued)
(C) The parietal pleura reflected, and several posterior ribs exposed. (D) The chest wall after excision of the posterior portions of four ribs.
Eurostile
28 ANTERIOR THORACOPLASTY
137
D
■
Figure 28–3
The upper two images reveal the presurgery and postsurgery clinical photographs of a patient who had an anterior thoracoplasty.
Note the significant cosmetic improvement, and the relative equal-
ity of the scapulae. The lower images depict the excellent radiographic correction achieved.
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SECTION II THE THORACIC SPINE
Eurostile
drainage, or hydrothorax if the tube has been removed. Should this occur,
the spinal fluid leakage is probably best controlled by a percutaneously
placed subarachnoid drain for several days. Avoiding this complications
requires careful dissection around the rib head, recognizing the location of
the neural foramen.
Complications
The complications of anterior thoracoplasty are in general no more than
those of thoracotomy. No differences in multiple parameters have been
noted in patients with anterior thoracoplasty compared to a historical
group that did not have the procedure. These parameters include operative
time, blood loss, extent of anterior and posterior procedures, discharge
day, and postoperative hematocrit. The only difference in the two groups
was thoracotomy tube days. Two thirds of patients required 3 days of thora-
cotomy tube drainage when thoracoplasty was performed; 95 % of patients
without thoracoplasty require only 2 days of thoracotomy tube drainage.
Neither hemothorax nor hydrothorax has been encountered after removal of the thoracotomy tube in patients undergoing anterior thoracoplasty, but it could occur. Thoracentesis should establish the nature of the
fluid in the chest. If blood, thoracentesis or replacement of a thoracotomy
tube manages this complication. If the fluid is spinal fluid, thoracotomy
tube and subarachnoid drainage may be considered.
If a posterior procedure follows the anterior, inspection of the residual
rib hump is possible. If there has been insufficient correction of the rib
hump by the anterior thoracoplasty, additional thoracoplasty may be accomplished from the midline posterior approach.
Postoperative Care
The postoperative care of the patient with anterior thoracoplasty is no
different from the patient with a thoracotomy. The thoracotomy tube is
placed to suction drainage. The tube can be removed when the drainage is
less than 200 cc in a 24-hour period. When the thoracotomy tube is removed, rehabilitation can proceed rapidly. No chest wall splints, casts, or
braces are employed, either for the thoracoplasty or for the spinal procedure. Antibiotics (cephazolin) are given at induction of anesthesia, and
every 8 hours after surgery for three doses.
Ambulation usually begins on the first or second postoperative day.
The patient usually progresses rapidly to independence. Hospital discharge occurs when the patient is independent, usually the fifth or sixth
day.Sedentary activity is permitted as tolerated. Significant sporting activity is not permitted for 6 months to permit arthrodesis to occur.
The addition of anterior thoracoplasty to the thoracotomy does not
delay any area of recovery or rehabilitation relative to the correction of the
spinal deformity by either anterior or posterior instrumentation. Figure
28–2 depicts the clinical and radiographic aspects of a patient with anterior thoracoplasty and correction of significant spinal deformity via anterior and posterior spinal procedures. The rib graft from the thoracoplasty
was more than sufficient for both the anterior and posterior arthrodesis.
Suggested Readings
Shufflebarger HL. Thoracoplasty: anterior technique. In: Bridwell K,
DeWald R, eds. The Textbook of Spinal Surgery. 2nd ed. Philadelphia:
Lippincott-Raven; 1997:463–468.
Shufflebarger HL, Smiley K, Roth HJ. Internal thoracoplasty: a new pro-
cedure. Spine 1994;19:840–842.
Steel HH. Rib resection and spine fusion in correction of convex deformity
in scoliosis. J Bone Joint Surg Am 1983;65:920.
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