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Roostaei G, Amini H, Abtahi H, Kazemizadeh H, Edalatifard M, Rahimi B, Asadi S, Khoshnam‐Rad N. Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports. Clin Case Rep 2024; 12:e8650. [PMID: 38464576 PMCID: PMC10920322 DOI: 10.1002/ccr3.8650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Abstract
Key Clinical Message Common complications after PE surgery include ventricular tachycardia, cardiac arrest, pneumothorax, and bar displacement. These can lead to severe outcomes, emphasizing the need for caution and meticulous post-operative monitoring. Patients and their families should be well-informed about potential risks during the consent process. Abstract The objective of this study was to raise awareness among medical staff and surgeons about potential complications, particularly rare and life-threatening ones, associated with pectus excavatum (PE) surgery. PE is the most common chest wall deformity, characterized by sternal depression. Patients primarily seek treatment for cosmetic concerns, but some also report exercise intolerance and shortness of breath. Although surgical repair is the standard treatment, the incidence and nature of severe complications remain unclear and underreported. This study presents a case of a lethal cardiac event following PE surgery and conducts a systematic review of published case reports. This study describes a case of a lethal complication of ventricular fibrillation and cardiac arrest following the Ravitch procedure for correction of PE in a 10-year-old boy. A systematic review of relevant cases of PE surgery complications was conducted. Of the 506 initial records retrieved, 93 case reports from 83 articles were identified over the 23 years. Among them, 72 patients were male, and 20 cases were female. The average age of patients was 19.2 ± 7.7 years (range: 5-53). Complications had occurred up to 37 years from the time of surgery, with most of the cases (22.5%) occurring during the operation. The most frequent complications included cardiothoracic issues and displacement of the implanted steel bar. In nine patients, complications led to fatal outcomes. Due to the possible risks of PE surgery, particularly in cosmetically motivated cases, surgeons must exercise extreme caution and remain vigilant for rare and potentially life-threatening complications.
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Affiliation(s)
- Ghazal Roostaei
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hesam Amini
- Department of Thoracic Surgery, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hamidreza Abtahi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hossein Kazemizadeh
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Maryam Edalatifard
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Besharat Rahimi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Sanaz Asadi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Niloofar Khoshnam‐Rad
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
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Fortmann C, Göen T, Wiesner S, Hegermann J, Kiblawi R, Dohna M, Ure BM, Renz DM, Petersen C, Kuebler JF. Titanium nitride coating of pectus bar increases metal contamination after minimally-invasive repair of pectus excavatum. PLoS One 2023; 18:e0292616. [PMID: 37824548 PMCID: PMC10569521 DOI: 10.1371/journal.pone.0292616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
INTRODUCTION Previous studies demonstrated a release of toxic metals, e.g. nickel and chromium, from stainless steel bars used for minimally invasive repair of pectus excavatum (MIRPE). In the present study, we investigated the impact of titanium nitride coating on the metal release and exposure of MIRPE patients. MATERIAL AND METHODS We analyzed the courses of nickel and chromium levels in blood, urine and local tissue in patients undergoing MIRPE with a titanium nitride coated pectus bar between 03/2017 and 10/2018. Sample collection was scheduled prior to MIRPE, at defined postoperative time points and at bar removal. Additionally, we evaluated irritative symptoms. Results were compared to a control group who received uncoated stainless steel bars in a previous time period (03/2015-02/2017). RESULTS 12 patients received coated pectus bars (mean age 15.7 years). The control group included 28 patients. After implantation of a titanium nitride coated bar, significant increase in systemic nickel and chromium levels after one, two and three years was noted. In an interim analysis one year after MIRPE, we observed patients with coated bars to have significantly elevated trace metal values compared to the control group. This elevation persisted throughout the observation period. Tissue metal values were also significantly increased. Irritative symptoms occurred significantly more often in study patients compared to controls (50.0% vs. 14.3%). CONCLUSIONS Coating of pectus bars with titanium nitride failed to reduce metal contamination after MIRPE. Instead, it resulted in a significant increase of trace metal levels after MIRPE, compared to patients with stainless steel bars, which may be explained by wear of the coating and inter-component mobilization processes.
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Affiliation(s)
- Caroline Fortmann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas Göen
- Social and Environmental Medicine, Institute and Outpatient Clinic of Occupational, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Soeren Wiesner
- Hannover Medical School, Institute for Biostatistics, Hannover, Germany
| | - Jan Hegermann
- Hannover Medical School, Research Core Unit Electron Microscopy, Institute of Functional and Applied Anatomy, Hannover, Germany
| | - Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Martha Dohna
- Department of Pediatric Radiology, Hannover Medical School, Institute of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Benno M. Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Diane Miriam Renz
- Department of Pediatric Radiology, Hannover Medical School, Institute of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F. Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Pereira-Nunes J, Vasconcelos-Castro S, Fontoura-Matias J, Preto-Gomes N, Marinho-Cunha A, Soares-Oliveira M. Preoperative Metal Patch Testing and Titanium Bar Use Criteria in Nuss Procedure: A 56-Patients' Cohort Study. Eur J Pediatr Surg 2022. [PMID: 35668642 DOI: 10.1055/a-1868-6224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Nuss procedure is the main reason for metal implants use by pediatric and thoracic surgeons. There is an ongoing debate on how to avoid allergic complications. Herein we describe our 8-year experience with systematic preoperative metal patch testing and our selective titanium bar use in Nuss procedure. MATERIALS AND METHODS This is a single center retrospective observational cohort study of patients who underwent the Nuss procedure from 2013 to 2020. Preoperative metal patch testing was done in all cases. Criteria for titanium bar utilization were: a positive test for a major component of the stainless-steel bar; or a positive metal patch test and a positive history of atopy, food or metal allergy, or previous allergic reaction to an implant or device. RESULTS In total, 56 patients were included. Most were male (91.1%) with a median age of 15.0 (13.0-22.0) years old. 19.6% had a positive preoperative metal patch test and 54.5% of these had no personal history of atopy. Stainless-steel bars were used in 27.3% of those patients and titanium bars were used in 72.7%. One patient had a documented minor allergy reaction. None of the 56 patients required early bar removal. CONCLUSION Our study suggests that routine preoperative allergy testing and a judicious use of titanium bar are safe and avoid metal allergic complications.
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Affiliation(s)
- Joana Pereira-Nunes
- Department of Pediatrics, Centro Hospitalar Universitário de São João Ringgold Standard Institution, Porto, Porto, Portugal.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Sofia Vasconcelos-Castro
- Department of Pediatric Surgery, Centro Hospitalar Universitário de São João Ringgold Standard Institution, Porto, Portugal
| | - José Fontoura-Matias
- Department of Pediatrics, Centro Hospitalar Universitário de São João Ringgold Standard Institution, Porto, Porto, Portugal.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nuno Preto-Gomes
- Department of Dermatology, Centro Hospitalar Universitário de São João Ringgold Standard Institution, Porto, Porto, Portugal
| | - Ana Marinho-Cunha
- Department of Dermatology, Centro Hospitalar Universitário de São João Ringgold Standard Institution, Porto, Porto, Portugal
| | - Miguel Soares-Oliveira
- Department of Pediatric Surgery, Centro Hospitalar Universitário de São João Ringgold Standard Institution, Porto, Portugal
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Fortmann C, Goeen T, Zinne N, Wiesner S, Ure BM, Petersen C, Kuebler JF. Nickel contamination after minimally-invasive repair of pectus excavatum persists after bar removal. PLoS One 2022; 17:e0275567. [PMID: 36215223 PMCID: PMC9550087 DOI: 10.1371/journal.pone.0275567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Minimally-invasive repair of pectus excavatum (MIRPE) has been shown to be associated with high release of trace metals into patient's body. The aim of our study was to analyze the kinetics of metal contamination after MIRPE and after bar removal. METHODS We prospectively assessed nickel and chromium changes in blood, urine, and local tissue in patients undergoing MIRPE with stainless-steel bar(s). Baseline samples were taken prior to surgery, further samples were taken at six defined time points until 30 months after bar removal. Clinical symptoms were evaluated at the time of every sample collection. RESULTS 28 patients were included (mean age 16.4 years). At four weeks after MIRPE and persisting up to bar removal, we found significantly elevated trace metal levels in blood and urine. Tissue nickel and chromium levels were significantly elevated at the time of bar removal. After bar removal, the concentration of trace metal in urine and the concentration of chromium in plasma decreased gradually. In contrast, nickel levels in blood further increased. Five patients showed irritative symptoms after MIRPE, all symptomatic patients had elevated metal levels. CONCLUSIONS Following MIRPE, we found a rapid systemic increase of nickel and chromium. Our data indicate that trace metal release could cause irritative symptoms. The prolonged elevated systemic nickel levels beyond bar removal necessitate further investigations of the long-term side effects of MIRPE.
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Affiliation(s)
- Caroline Fortmann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
- * E-mail:
| | - Thomas Goeen
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Norman Zinne
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Soeren Wiesner
- Institute for Biometry, Hannover Medical School, Hannover, Germany
| | - Benno M. Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F. Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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5
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Current Development of Minimally Invasive Repair of Pectus Excavatum (MIRPE). CHILDREN 2022; 9:children9040478. [PMID: 35455522 PMCID: PMC9024707 DOI: 10.3390/children9040478] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022]
Abstract
For decades, open surgical repair was the only available method to treat congenital and acquired chest wall deformities (CWDs). In 1998, D. Nuss described a minimally invasive procedure for surgical repair of Pectus excavatum (PE). Today, the Nuss procedure is performed with increasing frequency worldwide and considered as the “gold standard”. After its introduction, the method experienced numerous modifications such as routine thoracoscopy and/or sternal elevation, increasing safety of the procedure. Placement of multiple bars and/or the so called cross-bar technique were introduced to correct complex CWDs. Standardized pain management, the introduction of cryo-analgesia and a standardized postoperative physiotherapy program including deep breathing exercises facilitate the establishment of an enhanced recovery after surgery (ERAS) process. However, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. Furthermore, several studies report near-fatal complications, not only during bar placement, but also during bar removal. This review focuses upon the most relevant modifications, including recent published surgical techniques of MIRPE, in order to describe current developments in the field.
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Bouchard ME, Petrosyan M, Kane TD. Case series of metal allergy following Nuss procedure: Not only for stainless steel bars. J Pediatr Surg 2021; 56:1976-1981. [PMID: 33487461 DOI: 10.1016/j.jpedsurg.2021.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pectus excavatum is often managed with the Nuss procedure. Metal allergies to pectus bars occur in 5% of patients, though pre-operative testing is not generally routine. OBJECTIVES This study describes our experience with pre-operative metal allergy testing and post-operative allergic reactions to pectus bars. METHODS A retrospective study of patients who underwent a Nuss procedure at our institution from 2010-2020 was performed. Patients with documented "metal" allergy, defined by the need for and positive response to steroid treatment and the absence of infection, were included. Data on patient characteristics and clinical course were analyzed. RESULTS Five of 204 patients (2.5%) identified developed allergic metal reactions. Three of five patients developed allergic reactions to titanium bars, with two requiring early removal of the bar (< 2-3 years). Four patients required more than one course of steroids, and three required debridements for skin breakdown. All patients have maintained good surgical correction at one- and three-years post removal. CONCLUSIONS Pectus bar metal allergies occur with both stainless steel and titanium bars. Properly selected patients for pre-operative FinnⓇ Chamber testing may reduce the overall incidence of stainless-steel allergies but may miss titanium bar allergies. Early recognition and treatment of bar allergies may salvage the bar and avoid premature removal.
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Affiliation(s)
- Megan E Bouchard
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Mikael Petrosyan
- Department of General & Thoracic Surgery, Children's National Medical Center, Washington, DC, United States
| | - Timothy D Kane
- Department of General & Thoracic Surgery, Children's National Medical Center, Washington, DC, United States.
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7
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Lau FH, Chan JW, Chan H, Ng W. Nuss procedure for pectus excavatum: A patient with metal allergy. SURGICAL PRACTICE 2021. [DOI: 10.1111/1744-1633.12513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Joyce Wing‐yan Chan
- Department of Cardiothoracic Surgery Queen Elizabeth Hospital King's Park Hong Kong
| | - Hoi‐ming Chan
- Department of Cardiothoracic Surgery Queen Elizabeth Hospital King's Park Hong Kong
| | - Wing‐shun Ng
- Department of Cardiothoracic Surgery Queen Elizabeth Hospital King's Park Hong Kong
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8
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Torre M, Genova Gaia L, Calevo MG, Wong M, Raso M, Barco S, Di Gaudio F, Cangemi G. Blood metal levels after minimally invasive repair of pectus excavatum. Interact Cardiovasc Thorac Surg 2021; 33:76-81. [PMID: 33686408 DOI: 10.1093/icvts/ivab052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/01/2020] [Accepted: 12/12/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Minimally invasive repair of pectus excavatum (MIRPE) is the most popular surgical approach for paediatric patients with pectus excavatum. A substernal stainless still bar is inserted and left in place for 3 years and then removed. Our goal was to investigate blood metal levels after MIRPE and to correlate them with surgical details, such as the numbers of bars and stabilizers and the length of time the bar was in place. METHODS Blood levels of iron, chromium, manganese, molybdenum and nickel were analysed in 130 teenagers (108 boys and 22 girls) who had MIRPE using inductively coupled plasma mass spectrometry. A total of 62 patients were operated on using MIRPE (study group) and 68 patients were evaluated at implant time (control group). Differences between the numbers of bars implanted and the presence or absence of stabilizers were also considered. RESULTS Significant increases in the levels of abnormal chromium were found in patients in the study group compared with the controls (P = 0.02). When we compared the group of patients with 2 or more bars with the group with 1 bar, the percentage of patients with a value above the threshold increased by 29 (P = 0.05). A significant increase in chromium levels was observed in patients with stabilizers (P = 0.03). Above-threshold levels of molybdenum were found in 5.1% of patients in the control group, but the number was not statistically significant (P = 0.09). CONCLUSIONS We demonstrated that stainless steel devices used in MIRPE can elevate blood metal levels in paediatric patients. Moreover, we demonstrated that the use of metal stabilizers is associated with higher metal levels, probably due to increased dispersion.
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Affiliation(s)
- Michele Torre
- Pediatric Thoracic and Airway Surgery Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy.,Department of Pediatric Surgery, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Luca Genova Gaia
- Department of Pediatric Surgery, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Michela Wong
- Department of Pediatric Surgery, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maria Raso
- Chromatography and Mass Spectrometry Section, Quality Control and Chemical Risk (CQRC), Department PROMISE, University Palermo, Palermo, Italy
| | - Sebastiano Barco
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesca Di Gaudio
- Chromatography and Mass Spectrometry Section, Quality Control and Chemical Risk (CQRC), Department PROMISE, University Palermo, Palermo, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analyses, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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9
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Effect of Nitrided and Nitrocarburised Austenite on Pitting and Crevice Corrosion Resistance of 316LVM Steel Implants. MATERIALS 2020; 13:ma13235484. [PMID: 33272001 PMCID: PMC7730602 DOI: 10.3390/ma13235484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 11/28/2020] [Accepted: 11/29/2020] [Indexed: 11/16/2022]
Abstract
Harmful lesions occur in the body around multielement stabilisers made of AISI 316 LVM (Low Vacuum Melted) steel, caused by products of pitting, fretting or crevice corrosion. Preventing the effect is possible by modifying the surface of the steel implants. Therefore, the goal of the paper is the comparison of the mechanical and physiochemical properties of plates for treating deformations of the anterior chest wall made of AISI 316 LVM steel, subjected to diffusion and sterilisation processes and exposed to Ringer's solution. The surface of the implants was subjected to electrochemical polishing, chemical passivation and, in order to modify their properties, nitrocarburised and nitrided diffusion layers were created on selected stabilisers under glow discharge conditions with the use of an active screen at a temperature of 420 °C, over 60 min. The conducted studies involved the examination of the microstructure of the formed layers, surface roughness testing, analysis of contact angles and surface free energy, examination of resistance to pitting and crevice corrosion and examination of nanohardness. On the basis of the results of the conducted studies, it was established that the most advantageous set of properties after sterilisation and exposure to Ringer's solution was displayed by implants with a formed diffusion nitrocarburised layer.
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11
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Ozan S, Munir K, Biesiekierski A, Ipek R, Li Y, Wen C. Titanium Alloys, Including Nitinol. Biomater Sci 2020. [DOI: 10.1016/b978-0-12-816137-1.00018-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Ozan S, Lin J, Weng W, Zhang Y, Li Y, Wen C. Effect of thermomechanical treatment on the mechanical and microstructural evolution of a β-type Ti-40.7Zr-24.8Nb alloy. Bioact Mater 2019; 4:303-311. [PMID: 31709313 PMCID: PMC6829099 DOI: 10.1016/j.bioactmat.2019.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 12/11/2022] Open
Abstract
In this study, the microstructural evolution and mechanical properties of a newly developed Ti-40.7Zr–24.8Nb (TZN) alloy after different thermomechanical processes were examined. As-cast TZN alloy plates were solution-treated at 890 °C for 1 h, after which the thickness of the alloy plates was reduced by cold rolling at reduction ratios of 20%, 56%, 76%, and 86%. Stress-induced α” formation, {332} <113> β mechanical twinning, and kink band formation were observed in the cold-rolled TZN alloy samples. In the TZN sample after cold rolling at the 86% reduction ratio plus a recrystallization annealing at 890 °C for 1 h, the deformation products of a stress-induced α” phase, {332}<113> β mechanical twinning, and kink bands disappeared, resulting in a fine, equiaxed single β phase. The alloy samples exhibited elongation at rupture ranging from 7% to 20%, Young's modulus ranging from 63 to 72 GPa and tensile strength ranging from 753 to 1158 MPa. The TZN alloy sample after cold rolling and recrystallization annealing showed a yield strength of 803 MPa, a tensile strength of 848 MPa, an elongation at rupture of 20%, and an elastic admissible strain of 1.22%, along with the most ductile fractures during tensile testing. A newly developed Ti-40.7Zr–24.8Nb (TZN) alloy was thermomechanically processed. Deformation occurred via kink bands, mechanical twinning, and stress-induced α”. Cold rolling resulted in an increase in the tensile strength. Deformation products were disappeared after recrystallization annealing. TZN alloy can be considered as a promising candidate biomedical material.
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Affiliation(s)
- Sertan Ozan
- School of Engineering, RMIT University, Bundoora, Victoria, 3083, Australia
- Department of Mechanical Engineering, Yozgat Bozok University, 66100, Yozgat, Turkey
- Corresponding author. School of Engineering, RMIT University, Bundoora, Victoria, 3083, Australia.
| | - Jixing Lin
- Advanced Material Research and Development Center, Zhejiang Industry & Trade Vocational College, Wenzhou, Zhejiang, 325003, China
| | - Weijie Weng
- School of Engineering, RMIT University, Bundoora, Victoria, 3083, Australia
| | - Yaowu Zhang
- School of Engineering, RMIT University, Bundoora, Victoria, 3083, Australia
| | - Yuncang Li
- School of Engineering, RMIT University, Bundoora, Victoria, 3083, Australia
| | - Cuie Wen
- School of Engineering, RMIT University, Bundoora, Victoria, 3083, Australia
- Corresponding author.
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13
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Abstract
The Nuss procedure has become the predominant reason for the use of metal implants by pediatric general and thoracic surgeons. Current guidelines recommend preimplant testing for all patients undergoing the Nuss procedure, which differs from the guidelines for all other orthopedic procedures. This review was done to further evaluate this discrepancy.
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14
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Navratil M, Batinica M, Ivković-Jureković I. Metal allergy as a late-onset complication of the Nuss procedure in a pediatric patient. Pediatr Pulmonol 2018; 53:E24-E26. [PMID: 29897675 DOI: 10.1002/ppul.24072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/17/2018] [Indexed: 11/09/2022]
Abstract
We report the case of a 14-year-old boy with pectus excavatum who developed a metal allergy to stainless steel bar as a late-onset complication after the Nuss procedure. He did not have atopic diathesis. Treatment with oral steroids was effective and the metal bar was successfully removed 2 years later.
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Affiliation(s)
- Marta Navratil
- Department of Pediatrics, University Children's Hospital Zagreb, Zagreb, Croatia.,School of Medicine, University of Osijek, Osijek, Croatia
| | - Maja Batinica
- Department of Pediatrics, University Children's Hospital Zagreb, Zagreb, Croatia
| | - Irena Ivković-Jureković
- Department of Pediatrics, University Children's Hospital Zagreb, Zagreb, Croatia.,School of Medicine, University of Osijek, Osijek, Croatia
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15
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Goretsky MJ, McGuire MM. Complications associated with the minimally invasive repair of pectus excavatum. Semin Pediatr Surg 2018; 27:151-155. [PMID: 30078485 DOI: 10.1053/j.sempedsurg.2018.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The minimally invasive pectus excavatum repair (Nuss repair) is performed by pediatric general surgeons and pediatric and adult thoracic surgeons around the world. Complications related to pediatric surgical procedures are always a major concern for surgeons and their patients, and as with all surgery, especially pectus surgery, complications can be life-threatening. The purpose of this article is to discuss early and late complications of pectus excavatum surgery and potential preventive strategies to minimize them.
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Affiliation(s)
- Michael J Goretsky
- Children's Hospital of the Kings Daughters, Division of Pediatric General and Thoracic Surgery, 601 Children's Lane, Norfolk, VA 23507.
| | - Margaret M McGuire
- Children's Hospital of the Kings Daughters, Division of Pediatric General and Thoracic Surgery, 601 Children's Lane, Norfolk, VA 23507
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16
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Obermeyer RJ, Cohen NS, Gaffar S, Kelly RE, Kuhn MA, Frantz FW, McGuire MM, Paulson JF. Multivariate analysis of risk factors for Nuss bar infections: A single center study. J Pediatr Surg 2018; 53:1226-1229. [PMID: 29627175 DOI: 10.1016/j.jpedsurg.2018.02.090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND/PURPOSE Our previously published data suggested several risk factors for infection after the Nuss procedure. We aimed to further elucidate these findings. METHODS An IRB-approved (14-03-WC-0034), single institution, retrospective review was performed to evaluate the incidence of postoperative Nuss bar infections associated with seven variables. These were subjected to bivariate and multivariable analyses. A broad definition of infection was used including cellulitis, superficial infection with drainage, or deep infection occurring at any time postoperatively. RESULTS Over 7years (4/1/2009-7/31/2016), 25 (3.2%) of 781 patients developed a postoperative infection after primary Nuss repair. Multivariable analyses demonstrated an increased risk of infection with perioperative clindamycin versus cefazolin for all infections (AOR 3.72, p=.017), and specifically deep infections (AOR 5.72, p=.004). The risk of a superficial infection was increased when antibiotic infusion completed >60min prior to incision (AOR 10.4, p=.044) and with the use of peri-incisional subcutaneous catheters (OR 8.98, p=.008). CONCLUSION Following primary Nuss repair, the rate of deep bar infection increased with the use of perioperative clindamycin rather than cefazolin. The rate of superficial infection increased when perioperative antibiotic infusion was completed more than 60min prior to incision and with the use of peri-incisional subcutaneous catheters. Further studies are needed to better understand these findings. TYPE OF STUDY Retrospective chart review. LEVEL OF EVIDENCE Level III treatment study.
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Affiliation(s)
- Robert J Obermeyer
- Children's Hospital of the King's Daughters, Norfolk, VA; Eastern Virginia Medical School, Norfolk, VA.
| | | | | | - Robert E Kelly
- Children's Hospital of the King's Daughters, Norfolk, VA; Eastern Virginia Medical School, Norfolk, VA
| | - M Ann Kuhn
- Children's Hospital of the King's Daughters, Norfolk, VA; Eastern Virginia Medical School, Norfolk, VA
| | - Frazier W Frantz
- Children's Hospital of the King's Daughters, Norfolk, VA; Eastern Virginia Medical School, Norfolk, VA
| | - Margaret M McGuire
- Children's Hospital of the King's Daughters, Norfolk, VA; Eastern Virginia Medical School, Norfolk, VA
| | - James F Paulson
- Children's Hospital of the King's Daughters, Norfolk, VA; Eastern Virginia Medical School, Norfolk, VA; Old Dominion University, Norfolk, VA
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Obermeyer RJ, Gaffar S, Kelly RE, Kuhn MA, Frantz FW, McGuire MM, Paulson JF, Kelly CS. Selective versus routine patch metal allergy testing to select bar material for the Nuss procedure in 932 patients over 10years. J Pediatr Surg 2018; 53:260-264. [PMID: 29223667 DOI: 10.1016/j.jpedsurg.2017.11.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/08/2017] [Indexed: 11/28/2022]
Abstract
AIM OF THE STUDY The aim of the study was to determine the role of patch metal allergy testing to select bar material for the Nuss procedure. METHODS An IRB-approved (11-04-WC-0098) single institution retrospective, cohort study comparing selective versus routine patch metal allergy testing to select stainless steel or titanium bars for Nuss repair was performed. In Cohort A (9/2004-1/2011), selective patch testing was performed based on clinical risk factors. In Cohort B (2/2011-9/2014), all patients were patch tested. The cohorts were compared for incidence of bar allergy and resultant premature bar loss. Risk factors for stainless steel allergy or positive patch test were evaluated. MAIN RESULTS Cohort A had 628 patients with 63 (10.0%) selected for patch testing, while all 304 patients in Cohort B were tested. Over 10years, 15 (1.8%) of the 842 stainless steel Nuss repairs resulted in a bar allergy, and 5 had a negative preoperative patch test. The incidence of stainless steel bar allergy (1.8% vs 1.7%, p=0.57) and resultant bar loss (0.5% vs 1.3%, p=0.23) was not statistically different between cohorts. An allergic reaction to a stainless steel bar or a positive patch test was more common in females (OR=2.3, p<0.001) and patients with a personal (OR=24.8, p<0.001) or family history (OR=3.1, p<0.001) of metal sensitivity. CONCLUSION Stainless steel bar allergies occur at a low incidence with either routine or selective patch metal allergy testing. If selective testing is performed, it is advisable in females and patients with a personal or family history of metal sensitivity. A negative preoperative patch metal allergy test does not preclude the possibility of a postoperative stainless steel bar allergy. LEVEL OF EVIDENCE Level III Treatment Study and Study of Diagnostic Test.
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Affiliation(s)
- Robert J Obermeyer
- Children's Hospital of the King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
| | | | - Robert E Kelly
- Children's Hospital of the King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - M Ann Kuhn
- Children's Hospital of the King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Frazier W Frantz
- Children's Hospital of the King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Margaret M McGuire
- Children's Hospital of the King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - James F Paulson
- Children's Hospital of the King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA; Old Dominion University, Norfolk, VA, USA
| | - Cynthia S Kelly
- Children's Hospital of the King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
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18
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Fortmann C, Göen T, Krüger M, Ure BM, Petersen C, Kübler JF. Trace metal release after minimally-invasive repair of pectus excavatum. PLoS One 2017; 12:e0186323. [PMID: 29023602 PMCID: PMC5638555 DOI: 10.1371/journal.pone.0186323] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 09/18/2017] [Indexed: 11/18/2022] Open
Abstract
Background Several studies have shown a high incidence of metal allergy after minimally-invasive repair of pectus excavatum (MIRPE). We postulated that MIRPE is associated with a significant release of trace metal ions, possibly causing the allergic symptoms. Methods We evaluated the concentration with chromium, cobalt and nickel in blood, urine and tissue in patients prior to MIRPE and in patients who underwent an explantation of the stainless-steel bar(s) after three years. Results Our study group consisted of 20 patients (mean age 19 years) who had bar explantation and our control group included 20 patients (mean age 16 years) prior to MIRPE. At the time of bar removal we detected significantly elevated concentrations of chromium and nickel in the tissue compared to patients prior to the procedure (p<0,001). We also found a significant increase in the levels of chromium in urine and nickel in blood in patients three years post MIRPE (p<0,001). Four patients temporarily developed symptoms of metal allergy, all had elevated metal values in blood and urine at explantation. Conclusions Minimally-invasive repair of pectus excavatum can lead to a significant trace metal exposure.
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Affiliation(s)
- Caroline Fortmann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
- * E-mail:
| | - Thomas Göen
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Marcus Krüger
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Benno M. Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F. Kübler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Obermeyer RJ, Godbout E, Goretsky MJ, Paulson JF, Frantz FW, Kuhn MA, Lombardo ML, Buescher ES, Deyerle A, Kelly RE. Risk factors and management of Nuss bar infections in 1717 patients over 25 years. J Pediatr Surg 2016; 51:154-8. [PMID: 26563526 DOI: 10.1016/j.jpedsurg.2015.10.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/09/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE An increase in postoperative infections after Nuss procedures led us to seek risks and review management. We report potential risk factors and make inferences for prevention of infections. METHODS An IRB-approved retrospective chart review was used to evaluate demographic, clinical, surgical, and postoperative variables of patients operated on between 10/1/2005 and 6/30/2013. Those with postoperative infection were evaluated for infection characteristics, management, and outcomes with univariate analyses. RESULTS Over this 8-year period (2005-2013), 3.5% (30) of 854 patients developed cellulitis or infection, significantly more than 1.5% (13) in our previous report of 863 patients, 1987-2005 (p=.007). The most frequent organism cultured was methicillin-sensitive Staphylococcus aureus. Patients who were given clindamycin preoperatively (5 of 26 patients) had higher infection rates than those who received cefazolin (25 of 828) (19% vs 3%, p<.001). Patients treated with a peri-incisional ON-Q (I-Flow, Kimberly-Clark, Irvine, CA) also had higher infection rates (8.3% vs 2.4%, p<.001). Of the 30 patients who developed an infection, eighteen (60%) with cellulitis or superficial infections did not require surgical treatment or early bar removal. The other twelve patients (40%) with deep hardware infections required an average of 2.2 operations (range 1-6), with 3 (25%) requiring removal of their stabilizer and 3 (25%) requiring early bar removal. None of these three patients experienced recurrence of pectus excavatum at 2 to 4 years of follow-up. CONCLUSION Preoperative antibiotic selection and use of ON-Q's may influence infection rates after Nuss repair. Nuss bars could be preserved in 90% of all patients with an infection and even 75% of those with a deep hardware infection. Attempts to retain the bar when an infection occurs may help prevent pectus excavatum recurrence. Level of Evidence=III.
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Affiliation(s)
- Robert J Obermeyer
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Erin Godbout
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Michael J Goretsky
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Frazier W Frantz
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - M Ann Kuhn
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Michele L Lombardo
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - E Stephen Buescher
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Ashley Deyerle
- Children's Hospital of The King's Daughters, Norfolk, VA, USA
| | - Robert E Kelly
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
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