Sub peri-chondrial resection
I start by making a “H-shaped” incision with cautery in the peri-chondrial over each cartilage to be excised. This is easy enough along the straight upper cartilages. The lower ones which are oblique and rotated will make it difficult to perform perfect incisions but don’t worry. The important matter, particularly in children is not to go out as wide as the germinal centres at the ends of the ribs. Some surgeons use a knife to make these incisions but I find that makes for a lot of bleeding. The diathermy does tend to weld the peri-chondrium to the cartilage but I find this the lesser of two evils.

Perichondrial incision (Quicktime movie 11 secs 864K)
Now in turn each cartilage from the second to the costal margin is stripped of its peri-chondrium. The peri-chondrium is lifted with a combination of the force of an orthopaedic surgeon and the dexterity of a plastic surgeon, all the time knowing the heart is just behind if your hand slips. It is important to stay in the correct layer and not to drift out into the inter-costal space where you will cause bleeding.

Perichondrial flaps (Quicktime movie 20 sec 1.8Mb)

Once the peri-osteal elevator has lifted the peri-chondrium off the front of the cartilage the Doyen raspitory develops the posterior layer. I usually lever the cartilage forward with the peri-osteal elevator to guide the rongeur safely between the cartilage and peri-chondrium. Once around in the right layer it is quite straightforward to strip medially and laterally.

Completing perichondrial strip with Doyen (Quicktime movie 8 sec 316K)
Passing Doyen rib raspitory
Using the rongeur beneath the rib to protect the pleura and vessels, the cartilage is cut at each end. Some surgeons only cut a small section from the centre of each cartilage to free the sternum but I find it better to take most of the cartilage leaving the medial and lateral ends intact. In adults it is permissible and safe to dislocate the chondro-sternal junction. Cutting cartilage

Again the lower cartilages are difficult as they are triangular in cross section and frequently have bridges between them. A little imagination is needed to obtain a successful sub-periosteal strip. Make sure the extent of the repair is symmetrical. The points of the costal margins may seem prominent once the other cartilages are excised. It may be necessary to pull them well into the wound and cut them at the point they curve back laterally.

Sternal release
At this stage the sternum is still held in place by the inter-costal muscles and diaphragmatic adhesions. If these are not divided, no metal bar made by man will withstand the constant rhythmic bending force of the chest wall muscles.

Divide the soft tissue from the tip of the xiphisternum to allow a finger to be placed under it. Develop the sub-sternal plane by sweeping the pleura laterally on each side. You will probably enter the pleura - don’t worry.The terminal branches of the IMA’s will be divided at this stage if they have not previously been so.

Each successive neuro-vascular (NV) bundle is divided close to the sternum. You can feel the sternum elevate with each NV cut.The NV bundles usually need to be divided as far up as the second cartilage which is the usual limit of the sub-periosteal resections. It should be possible to hold the sternum up with one finger lightly applied to the tip. Care must be taken with branches of the IMA. Usually at least one IMA is sacrificed. I attempt to keep at least one to ensure viability of the sternum.

Dividing neurovascular bundles (Quicktime movie 15 sec 884K)
Freeing neurovascular bundles

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