Titanium Man: A new chest wall for pectus patient

By Rich Radford
Video by Elizabeth McDougall and Rich Radford

After three failed attempts to fix a severe chest wall deformity, 26-year-old Richard Cole had almost given up hope.

Richard was born with pectus excavatum, a condition in which the chest wall indents. It is also called sunken chest syndrome. He had his first surgery, called a Ravitch Procedure, at age 5. Surgeons opened his chest and attached a bar to his sternum in an attempt to create a normal chest cavity. In the process they removed cartilage with the expectation that it would regenerate.

But the correction didn’t hold, and Richard’s chest wall began to collapse again.

His second surgery, when he was 14, revealed a bigger problem: The cartilage tissue that had been removed nine years earlier never grew back. The planned procedure could not be completed.

“I had been told there was a 90 percent chance of success and those are good betting odds,” says Richard. “I bet the house on it emotionally and it failed. That was crushing.”

When he was 20, Richard turned to a military surgeon who specialized in chest wall trauma, with experience operating on soldiers returning from Afghanistan. The surgeon implanted synthetic mesh between Richard’s heart and sternum with the hope that it would foster bone and cartilage regeneration and provide protection to his vital organs.

That didn’t work either.

“You could see my heartbeat through my skin,” says Richard, who lives at Smith Mountain Lake near Roanoke, Va. “If I had been in a car accident, the steering column or even just an air bag would have caused enough blunt-force trauma to kill me instantly.”

The deformity also caused significant breathing difficulties, but after three failed surgeries Richard became resigned to living with limitations.

“Then one day I learned about Children’s Hospital of The King’s Daughters through my little brother’s doctor,” says Richard. “He told me that CHKD did amazing things with chest wall repair.”

CHKD became a leader in pediatric chest wall repair when surgeon Donald Nuss created a minimally invasive surgical approach to correct pectus excavatum. For nearly 30 years, CHKD has been perfecting the Nuss Procedure and leading international research and innovation in the field of chest wall repair.

Richard made an appointment with Dr. Frazier Frantz, one of CHKD’s pediatric surgeons.

“Richard was suffering from a condition called flail chest in which broken or absent cartilaginous ribs compromise normal breathing,” says Dr. Frantz. “When a person with flail chest takes a breath in, the sternum is sucked inward and the lung expansion is inhibited. Breathing in this manner is very inefficient and severely limits exercise capability and quality of life.

“Beyond the effects on his lungs, this condition also caused Richard chronic pain, which further limited his activity.”

“Dr. Frantz said I was not an efficient cardiopulmonary machine,” says Richard. “I wasn’t oxygenating properly. I was in a very bad place in terms of my health.”

Dr. Frantz was moved by Richard’s situation.

“I didn’t want him to go through life in a catcher’s chest protector, says Dr. Frantz. “He deserved a better solution.”

Based upon his previous experience with titanium inserts to correct other chest wall deformities, Dr. Frantz envisioned a revolutionary surgical approach.

Dr. Frantz took MRI images and CT scans of Richard’s chest to engineers at Biomet Microfixation, which manufactures the Nuss bar, and told them Richard’s story. The company had done jaw implants. This case and this implant would be much more complex, but they wanted to try.

After months of planning, the engineers crafted four titanium plates that would be attached to Richard’s remaining sternum and ribs. Fitted together, the plates resembled a chest shield that any superhero would be proud to wear.

But this shield would be worn internally. To insert it, Dr. Frantz assembled CHKD’s experienced chest wall surgical team, which has collaborated on thousands of chest wall repairs. Three of the Biomet engineers flew from Jacksonville, Fla., to Norfolk, Va., to observe the groundbreaking surgery.

In the operating room, Dr. Frantz fractured Richard’s sternum to create a smooth surface for the titanium plates to rest upon. The four plates came together like a puzzle in the middle of Richard’s chest. Then Dr. Frantz and his team attached the plates to the ribs with more than 70 screws. The screws are of varying lengths, all mapped out for size and depth for optimum stability and safety. Once the plates were in place, his pectoral muscles were stretched across the top surface to create a normal-looking chest wall and to provide protection.

When Richard awoke following more than seven hours of surgery, he was so ecstatic that he tried to get out of bed and walk almost immediately.

“You know those YouTube videos you see of patients who get hearing implants and they start crying because they can hear for the first time? That’s what it was like for me,” says Richard. “I was taking deep breaths for the first time in my 26 years of life.

“I could breathe for the first time and the tears … I couldn’t stop crying because I was so happy. I was euphoric. I wanted to get up and walk almost immediately.”

By that evening, with the aid and under the watchful eyes of his physical therapists, he was up and walking through CHKD’s hallways.

When Dr. Frantz tested Richard’s breathing capacity two days after surgery, he was astounded. “He was breathing in 2 liters of air per breath,” says Dr. Frantz. “That’s a lot for anyone, and his body has never had this type of lung capacity.”

While the new titanium ribs don’t offer the flexibility of a typical rib cage, the tradeoff is increased lung capacity as well as stability and protection for his most vital organs.

At 6-foot-4, Richard has the long, lean look of a basketball player, yet his decreased lung function and the threat of an inadvertent elbow bruising or even stopping his heart had robbed him of a favored pastime.

Less than 24 hours after surgery, Richard was talking of playing basketball again and competing in 10-mile obstacle-course races that test an individual’s endurance. As he sees it, the sky is the limit and he has a superhero’s chest plate to prove it.

Dr. Frantz tempers his enthusiasm for Richard’s results thus far with cautious optimism. “We have never attempted a repair this extensive,” he says. “This is case No. 001, so we will be keeping close tabs on Richard to see how he does over time.”

“I just wish Dr. Frantz had put a light bulb in my chest,” says Richard, comparing his new chest to that of Iron Man, the Marvel comic book and movie action hero. “That would have been cool.”

He’ll have to settle for being Titanium Man.