Bracing of pectus carinatum: A quantitative analysis

Bracing of Pectus Carinatum in Children: Current Practices

BACKGROUND

Although effective, compressive orthotic bracing (COB) in children with pectus carinatum is still not standardized. This study has aimed to analyze current practices amongst members of the Chest Wall International Group (CWIG).

METHODS

A web-based questionnaire was mailed to all CWIG members at 208 departments. It included 30 questions regarding diagnostic work-up, age for COB indication, type of COB used, daily wearing time, treatment duration, complications, and recurrence rate.

RESULTS

Members from 44 departments have responded (institutional response rate 21.2%). A total of 93% consider COB as the first-line treatment for PC. A conventional COB (CC) is used in 59%, and the dynamic compression system (FMF) in 41%. The overall compliance rate is >80%. A total of 67% of responders consider COB to be indicated in patients <10 years. The actual wearing time is significantly shorter than the physician-recommended time (p < 0.01). FMF patients experience a significantly faster response than CC patients (p < 0.01). No recurrence of PC has been noted in 34%; recurrence rates of 10-30% have been noted in 61%.

CONCLUSIONS

COB is the first-line treatment for PC with a high compliance rate. During puberty, the recurrence rate is high. Treatment standardization and follow-up until the end of puberty are recommended to enhance COB effectiveness.

Remote Monitoring System of Dynamic Compression Bracing to Correct Pectus Carinatum

Pectus carinatum (PC) is a chest deformity caused by disproportionate growth of the costal cartilages compared with the bony thoracic skeleton, pulling the sternum forwards and leading to its protrusion. Currently, the most common non-invasive treatment is external compressive bracing, by means of an orthosis. While this treatment is widely adopted, the correct magnitude of applied compressive forces remains unknown, leading to suboptimal results. Moreover, the current orthoses are not suitable to monitor the treatment. The purpose of this study is to design a force measuring system that could be directly embedded into an existing PC orthosis without relevant modifications in its construction. For that, inspired by the currently commercially available products where a solid silicone pad is used, three concepts for silicone-based sensors, two capacitive and one magnetic type, are presented and compared. Additionally, a concept of a full pipeline to capture and store the sensor data was researched. Compression tests were conducted on a calibration machine, with forces ranging from 0 N to 300 N. Local evaluation of sensors' response in different regions was also performed. The three sensors were tested and then compared with the results of a solid silicon pad. One of the capacitive sensors presented an identical response to the solid silicon while the other two either presented poor repeatability or were too stiff, raising concerns for patient comfort. Overall, the proposed system demonstrated its potential to measure and monitor orthosis's applied forces, corroborating its potential for clinical practice.

Ten-year experience with staged management of pectus carinatum: Results and lessons learned

INTRODUCTION

We report pectus carinatum management over a 10+year period.

METHODS

Staged management, with initial bracing and operation for failure or special circumstances, was employed. A newer brace and a minimally invasive operation for PC (the Abramson procedure) were introduced during the study period.

RESULTS

Of 695 consenting patients from 2008 to 2018, 265 (38%) were observed. Of 430 treated, 339 (79%) had bracing only; 65 (15%) underwent surgery without a trial of bracing, while 26(5%) underwent surgery after a failed attempt at bracing. Of 364 bracing patients, 144 (40%) were successful, 77 (21%) are ongoing, 25 (7%) failed, and 118 (32%) dropped out. Recurrence was noted in 17 (5%), an average 5.4 months later. Two (0.4%) overcorrected to pectus excavatum (PE). Successful patients experienced a 50% decrease in pressure of correction (POC) beginning one month after starting treatment. Brace failure patients did not. Reported compliance with brace utilization (hours/day) was similar. Surgery was required in 91 patients. Open operations were performed in 61 (67%), Abramson operations in 23 (25%), and Nuss procedure in 7 (8%) who developed excavatum over correction following bracing or who had mixed deformity, with excavatum one side of the sternum and carinatum on the other. Twenty-four (36%) of the surgeries for PC occurred after an attempt at bracing. All obtained good initial results by operation. No recurrence was noted after open operation and 3 (13%) after Abramson. Open complications included 1 (2%) infection. Abramson's operation required 11 (48%) revisions, 6 (26%) early bar removals, and had 3 (13%) infections.

CONCLUSION

Brace treatment for PC can be guided by pressure of correction, which fell by more than half in successfully treated patients. POC did not fall in patients who failed. If POC does not fall, surgery should be considered. Open repair of Pectus Carinatum is generally successful, while the Abramson operation has a significant rate of complications with the implants currently available in the U.S.

LEVELS OF EVIDENCE

Level III - Retrospective comparative study.

Evolving Business Models in Orthotics

This submission provides an important historical context for understanding the current challenge facing the Orthotic and Prosthetic community in Alberta including Alberta Aids to Daily Living (AADL), Suppliers, and Providers: maintaining sustainable access to Orthotic care for people with mobility disorders in the face of declining real rates of reimbursement combined with increasing costs and a shortage of skilled Clinicians. Under the Canada Health Act, the federal government delegates responsibility for providing health care to the provinces. This delegation of responsibility to the provinces results in a degree of variability of funding of Orthotics and Prosthetics between provinces across the country. Funding of Orthotics and Prosthetics in Alberta is characterized by structural inequities that favour Prosthetics at the expense of Orthotics. To the extent that the structural inequities that exist in Alberta are related to governance by volunteer-run, non-profit organizations, they may be generalized to the Canadian experience. Finally, in a Call to Action a number of recommendations are made to address the challenge of sustainable access to Orthotic care in Alberta serving as a model for other provinces across Canada.

Outcomes Following Dynamic Compression Bracing for Pectus Carinatum

Introduction: Children with pectus carinatum (PC) are particularly vulnerable to psychosocial effects of poor body image, even though they may not experience physical symptoms. Nonoperative treatment with orthotic bracing is effective in PC correction. We describe our experience with dynamic compression bracing (DCB) for PC patients and their satisfaction with bracing. Materials and Methods: Prospective institutional data of patients undergoing DCB from July 2011 to June 2018 were reviewed and analyzed for those who entered the retainer mode after correction, defined by a correction pressure of <1 psi. A telephone survey was conducted regarding their bracing experience and satisfaction with the outcome on a scale of 1-10. Results: Of 460 PC patients, 144 reached the retainer mode. Median time to retainer mode was 5.5 months. There was no statistically significant relationship between initial correction pressure or carinatum height and time to retainer mode (P = .08 and P = .10, respectively). Fifty-seven percent were compliant with brace use, and median time to retainer mode in this subset was significantly shorter than noncompliant patients (3.5 months versus 10 months, P < .001). Fifty-three percent responded to the survey 13 months [interquartile ratios 3, 33] after the last clinic visit. The main barrier to compliance with wearing the brace was discomfort (37%), while the main motivation for compliance was appearance (58%). All endorsed bracing as worthwhile, with 94% reporting a satisfaction rating of 8 or greater for the correction outcome. Conclusion: DCB is effective in achieving correction of PC in compliant patients. Regardless of time to retainer mode, patients reported high satisfaction with bracing.

A Sensor System to Measure Force Applications of a Brace for Pectus carinatum

Pectus carinatum (PC) presents itself as a protrusion on the chest wall of adolescent individuals. Current treatment for PC is performed with a Pectus carinatum orthosis (PCO) that applies a compressive force to the protrusion. While this treatment is accepted, the magnitude of compressive forces applied remains unknown leading to excessive or deficient compression. Although the need for this quantitative data is recognized, no studies reporting the data or methods are available. The purpose of this study was to design an accurate force measurement system (FMS) that could be incorporated into a PCO with minimal bulk. Components of the FMS were three-dimensional (3D)-printed and incorporated into an existing PCO design. The FMS was calibrated using a custom indenter that applied forces to the FMS in a controlled manner. Evaluation of the FMS on five human participants was also performed. A reliability measure of the FMS was calculated for analysis. The FMS was implemented into the PCO and able to withstand the applied forces. The calibration revealed an increase in load cell error with increased magnitude of applied force (mean error [SD] = 5.59 N [6.48 N]). Participants recruited to evaluate the FMS demonstrated reliable forces (R = 96%) with smaller standard deviations than those during the calibration. The FMS was shown capable of measuring PCO forces but requires further testing and improvement. This system is the foundational component in a wireless, minimalistic sensor system to provide real time force feedback to both the clinician and patient.