Restoring thoracic stability with rigid titanium rib reconstruction after radical forequarter and upper chest wall resection for T4 chondrosarcoma

Abstract

Extensive anterior chest wall involvement in chondrosarcoma presents major reconstructive challenges following radical oncologic resection. A 55-year-old man with cT4N0M0 chondrosarcoma involving the right shoulder girdle, ribs 1–4, and right upper lobe underwent en bloc extended forequarter amputation, multilevel rib resection, and right upper lobe segmentectomy. Chest wall reconstruction was performed using a titanium-based RibLoc plating system with vascularized soft-tissue flap coverage. Postoperatively, chest wall stability was preserved without paradoxical motion, and radiographs confirmed appropriate implant positioning. The patient was successfully weaned from mechanical ventilation on postoperative day two and transferred from the intensive care unit on day three without major complications. Rigid titanium rib fixation provided effective structural restoration and favorable early postoperative outcomes following extensive anterior chest wall resection for advanced chondrosarcoma.

Introduction

Chondrosarcoma is the second most common primary malignant bone tumor and is characterized by the production of cartilaginous matrix by malignant mesenchymal cells [1]. The tumor commonly affects the pelvis, femur, and shoulder girdle, predominantly in adults between 30 and 50 years of age [1]. Surgical resection with negative margins remains the primary treatment modality because chondrosarcoma generally demonstrates limited responsiveness to chemotherapy and radiotherapy [1, 2]. Chest wall chondrosarcoma involving the shoulder girdle and upper thoracic structures presents substantial surgical and reconstructive challenges. Extensive tumor invasion often necessitates radical procedures such as forequarter amputation combined with multilevel rib resection to achieve adequate oncologic clearance. However, these resections create large anterior chest wall defects that may compromise thoracic stability, respiratory mechanics, and protection of intrathoracic organs. Rigid chest wall reconstruction using titanium plating has emerged as a promising strategy to restore biomechanical integrity and prevent paradoxical chest wall motion following extensive thoracic resection [3–5]. Nevertheless, reports describing combined forequarter amputation with multilevel anterior chest wall reconstruction using rigid fixation remain limited. We present a case of advanced chest wall chondrosarcoma treated with extended forequarter amputation and titanium-based rigid chest wall reconstruction, highlighting the surgical technique and early postoperative outcomes.

Objectives

This case report aims to describe the reconstructive approach using titanium-based rigid fixation following forequarter amputation and multilevel anterior chest wall resection, as well as to evaluate early postoperative outcomes in maintaining thoracic stability and respiratory function.

Case presentation

A 55-year-old man presented with progressive right shoulder pain associated with an enlarging mass causing functional impairment of the right upper extremity. There was no history of trauma or significant comorbidities. Physical examination revealed a firm mass extending from the right shoulder to the anterior chest wall with ill-defined margins (Fig. 1). The patient was hemodynamically stable. Chest radiography demonstrated a large soft tissue mass in the right hemithorax associated with destruction of the humerus and multiple ribs. Computed tomography (CT) revealed an extensive tumor involving the right shoulder girdle with invasion of ribs 1–4 and the right upper lobe lung parenchyma (Fig. 2). Histopathological examination showed atypical chondrocytes within a cartilaginous matrix with mild-to-moderate pleomorphism, binucleation, and low mitotic activity without necrosis, consistent with grade I chondrosarcoma (Fig. 3).

Following multidisciplinary discussion involving cardiothoracic surgery, oncology, plastic surgery, and anesthesiology teams, the patient underwent en bloc extended forequarter amputation combined with resection of ribs 1–4 and right upper lobe segmentectomy. The resected specimen measured ~30 × 22 × 12 cm, demonstrating extensive local invasion into the chest wall and surrounding soft tissues (Fig. 4). The resulting full-thickness anterior chest wall defect was reconstructed using a titanium-based rigid fixation system (RibLoc system) applied according to the physiological rib curvature to restore thoracic stability and prevent paradoxical motion (Fig. 4). Soft tissue coverage was achieved using a well-vascularized regional flap to protect intrathoracic structures and prosthetic material.

Postoperatively, the patient was managed in the intensive care unit with mechanical ventilatory support, hemodynamic monitoring, and multimodal analgesia. The patient was successfully extubated on postoperative day 2 and transferred from the intensive care unit on postoperative day three in stable condition. Postoperative chest radiography confirmed appropriate implant positioning without displacement and demonstrated adequate lung expansion (Fig. 5). Flap perfusion remained satisfactory, and no early postoperative complications such as respiratory compromise, wound infection, or reconstruction failure were observed.

Discussion

Chondrosarcoma is a malignant cartilaginous tumor that demonstrates limited responsiveness to chemotherapy and radiotherapy, making complete surgical resection with negative margins the cornerstone of treatment [1, 6]. In advanced chest wall involvement, achieving adequate oncologic clearance often requires extensive resection involving the ribs, surrounding soft tissue, and adjacent intrathoracic structures. In the present case, tumor invasion of ribs 1–4 and the right upper lobe necessitated radical en bloc resection combined with extended forequarter amputation. Extensive anterior chest wall resection may result in thoracic instability, impaired respiratory mechanics, and paradoxical chest wall motion. Therefore, reconstruction plays a critical role in restoring structural integrity and maintaining ventilatory function. Titanium-based rigid fixation systems have become increasingly favored because they provide superior biomechanical stability compared with non-rigid reconstruction techniques [3–5]. In this patient, rigid plating successfully restored chest wall continuity and maintained thoracic stability, as demonstrated by the absence of paradoxical motion and adequate postoperative lung expansion. Soft tissue reconstruction is also essential to protect prosthetic material, improve vascularized coverage, and reduce the risk of infection or implant exposure. The use of a vascularized regional flap in this case contributed to satisfactory wound healing and preserved flap viability during the postoperative period. No early respiratory, infectious, or reconstructive complications were observed. Reports describing combined extended forequarter amputation and multilevel anterior chest wall reconstruction using rigid titanium fixation remain limited in the literature. This case demonstrates that aggressive oncologic resection combined with rigid skeletal reconstruction and vascularized soft tissue coverage can achieve favorable early functional and respiratory outcomes in patients with extensive chest wall chondrosarcoma.

Conclusion

Rigid titanium chest wall reconstruction provided effective structural restoration following extended forequarter amputation and multilevel anterior chest wall resection for advanced chondrosarcoma. The combination of rigid skeletal fixation and vascularized soft tissue coverage successfully maintained thoracic stability, preserved respiratory function, and resulted in favorable early postoperative outcomes without major complications. This case highlights the feasibility of combining aggressive oncologic resection with modern rigid chest wall reconstruction in complex anterior thoracic defects.

Conflicts of interest

None declared.

Funding

None declared.

References