Complications Related to Pectus Carinatum Correction: Lessons Learned from 15 Years’ Experience. Management and Literature Review

The individualized treatment for minimally invasive repair of pectus carinatum in adolescent: a single center' s retrospective study

BACKGROUND

Pectus carinatum (PC) mainly present at the growth spurt time of the early teenage years or the puberty. Poor outer appearance is a major reason for seeking help for surgeons to increase self-confidence and self-esteem. At present, minimally invasive repair (MIR) is one of effective ways to correct the chest wall deformity. Therefore, there is great practical significance to conduct clinical research on MIR about the adolescent PC.

METHODS

We applied Abramson procedure in PC group or we applied Abramson procedure and Nuss procedure in PC/PE group. We retrospectively reviewed the results of 41 cases who underwent the surgical correction at our department from January 2020 to April 2023.

RESULTS

All the procedures were successfully done without severe complications. The median operation Time was 80 min in PC group while was 130 min in PC/PE group. The median LOS were 4 days in PC group while 5 days in PC/PE group. The median compression depth was 32 mm in PC group while 12 mm in PC/PE group. Postoperatively, there are some complications. All Pneumothorax patients being treated conservatively were found in 9 patients in two groups. One patient suffered overcorrection after operation. There were 3 patients suffered steel wires breakage in two groups. One patient reoperation postoperatively for the dislocation of the bar secondary to steel wires breakage.

CONCLUSIONS

The Abramson procedure or Abramson procedure and Nuss procedure have good short-term results in repair PC and PC/PE. Select one or two procedures should be done individually based on whether the lower plane over depressed after Abramson procedure.

A new custom-made bivalve brace for pectus carinatum in children and adolescents: preliminary promising experience of 140 patients from a tertiary center

Introduction

International research suggests that poor patient compliance is the main cause of tutor failures in the context of potential novel orthopedic bivalve braces for conservative treatment of pectus carinatum. Our entire experimental study is based on the hypothesis that a rigid bivalve brace that patients can accept could solve the main problem associated with the conservative approach-poor compliance. The hypothesis was to reduce the thickness and weight of the classic bivalve brace to ensure concealment and make it sustainable enough to be worn several hours a day without compromising its therapeutic efficacy.

Materials and method

The research was conducted from January 2020 to December 2022 to ensure follow-up of all participants for at least 6 months. In 36 months, 140 patients with pectus carinatum were assessed and conservatively treated with the studied guardian to analyze the therapeutic efficacy of the bivalve brace and patient compliance. From the initial visit, the parents and patient were informed that this is a 2-year therapeutic course during which the bivalve brace should be worn at least 23 h a day (with 1 h of abstinence per day for routine personal hygiene practices). Compliance is the key to therapy success, and the duration of treatment depends on patient adherence.

Results

The exceptional effectiveness of the experimental brace was confirmed by both the questionnaire from the patients (with an average satisfaction rate of 8.9/10) and an assessment of the therapy's results by a properly selected medical committee (with a VAS scale satisfaction of 7.2/10 for symmetric forms and 7.1/10 for asymmetric ones).

Conclusion

In conclusion, the analyzed data confirmed the research hypotheses. First, none of the 140 patients had cardiovascular diseases directly related to their condition, confirming that pectus carinatum is a pathology of a purely aesthetic nature. Second, a cheap, lightweight, and easily obscured brace significantly improved patient compliance. Along with this, the social relevance of the aesthetic aspect today may be an important factor in motivating the study cohort to adhere to therapy. In the past, esthetics and appearance were less relevant at the social level, which may have contributed to the high abandonment and reduced compliance rates of the many studies in the literature.

Ravitch Surgery or Dynamic Compression Bracing for Pectus Carinatum: A Retrospective Cohort Study

BACKGROUND

Pectus carinatum is a pediatric condition that can be treated by dynamic compression system (DCS) bracing or surgery. Several publications on DCS bracing or surgery are available; however, they do not compare both treatments.

METHODS

Over a 10-year period, 738 patients with pectus carinatum were treated at the Amsterdam Pectus Center (Amsterdam, The Netherlands). This study describes this 10-year experience and the results of both treatments.

RESULTS

Of the 631 patients who underwent DCS bracing treatment, 553 finished treatment, and 78 patients are still under treatment. A total of 73.8% (n = 408) of these patients finished treatment successfully, 13.6% (n = 75) experienced treatment failure, and 12.7% (n = 70) were lost to follow-up. The success rate decreased with an increasing pressure of initial compression (84.2%-67.3%). Marfan syndrome and Poland syndrome were associated with unfavorable results. Ravitch surgery was performed in 105 patients, with a success rate of 92.4%. Complications occurred in 32.4% of patients, and 6.7% of patients had complications for which surgery was needed. No relationship was found between osteotomy or sternal fixation and outcomes or complications. The Abramson procedure was performed in 2 patients.

CONCLUSIONS

DCS bracing should be the treatment of choice in patients with pectus carinatum because of its noninvasiveness, good results, and lower complication rate compared with surgery. Besides pressure of initial correction, motivation is an important factor influencing outcomes, and compliance remains a major challenge in treating pectus carinatum using DCS bracing. Bracing patients before their growth spurt should be discouraged. Patients with a higher pressure of initial compression (>8.0-8.5 psi) and Marfan syndrome or Poland syndrome have poorer outcomes. In those patients, surgery may be considered.

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.

Use of cryoanalgesia as a postoperative pain management for open pectus carinatum repair

PURPOSE

Cryoanalgesia has shown to have safety and efficacy as an adjunct post-operative pain management for Nuss procedure. One retrospective study reported its efficacy for analgesia with the Ravitch procedure, with improved pain scores and decreased length of stay versus thoracic epidural. We describe our initial experience with the use of cryoanalgesia for an open repair of pectus carinatum.

METHODS

We retrospectively reviewed the medical records of all patients who received cryoanalgesia during an open repair of pectus carinatum from 2016 to 2019 at our institution. We recorded pain scores at immediate post-operative and at 1-week follow up after hospital discharge. Length of stay and mean follow up time were also recorded.

RESULTS

Five pediatric patients underwent open repair of pectus carinatum with cryoanalgesia. The median postoperative length of stay (LOS) was 1 (range 1-2) day. Only one patient reported a non-zero pain score during their hospitalization, and this was a 3 out of 10 in the post-analgesia care unit. At 1-week postoperative visit, all patients had a pain score of 0. Median follow up was 1 (0.5-2) year. No patients developed neuralgia.

CONCLUSION

Cryoanalgesia is a safe and effective pain management strategy for pediatric patients undergoing open pectus carinatum repair.

Initial reduction of flexible pectus carinatum with outpatient manipulation as an adjunct to external compressive bracing: technique and early outcomes at 12 weeks

INTRODUCTION

Our aim was to assess whether initial reduction with outpatient soft-tissue manipulation of flexible pectus carinatum deformity prior to external compressive bracing was associated with improved compliance and patient satisfaction compared to reported outcomes of external brace with progressive tightening.

MATERIALS AND METHODS

From our observational cohort of 227 patients, 177 were felt appropriate to undergo initial reduction and soft tissue manipulation prior to immediate custom fitting of an external compressive brace. These patients then followed a prescriptive schedule of 12 weeks of continuous external bracing with subsequent follow-up in clinic.

RESULTS

The reduction in Haller Index was maintained throughout the period of external bracing without the need for progressive tightening of the external brace. The treatment was associated with high levels of patient satisfaction and high patient concordance compared to other protocols. There were no major complications and minor complications included only skin irritation.

CONCLUSIONS

Out-patient initial reduction with manipulation prior to external compressive bracing is a novel technique which resulted in excellent concordance and high rates of patient satisfaction and should be considered as an adjunct to standard external bracing techniques.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level II.

Sternocostal instability after Ravitch repair in adolescents; 3 case-reports and a review of surgical techniques in the literature

Ravitch repair is a common surgical procedure to correct chest wall deformities. In this procedure, a subperichondreal cartilage resection of the deformed parasternal cartilage, and if necessary a repositioning of the sternum, is performed. Insufficient regeneration of the resected cartilage may result in sternocostal instability or even floating sternum. This rare complication presents with symptoms of pain and exercise intolerance.

External Compressive Bracing With Initial Reduction of Pectus Carinatum: Compliance Is the Key

BACKGROUND

To assess the impact of manipulation and a tailored program for compressive bracing on the quality of life of patients with flexible pectus carinatum.

METHODS

Two hundred forty-nine sequential patients attending a clinic for assessment of pectus carinatum deformities underwent outpatient manipulation and then followed a prescribed schedule of continuous external compressive bracing but without significant progressive tightening.

RESULTS

There was successful sustained reduction of the deformity in 244 patients with high reported rates of concordance (98%) and satisfaction (94%). Patients experienced a reduction in symptoms of anxiety and depression (P < .001) and had improved body satisfaction (P < .001). Mild skin irritation occurred in 18% of patients (n = 44), and there were 2 severe cases of skin irritation, 1 of which resulted in abandonment of bracing.

CONCLUSIONS

Manipulation and nontightening compressive bracing was associated with complete concordance, high levels of successful bracing, improved confidence, and reduced psychological morbidity.

Pain and sensory disturbances following surgical repair of pectus carinatum

BACKGROUND/PURPOSE

The purpose of this study was to assess the characteristics of persistent postoperative pain and sensory disturbances following surgical repair of pectus carinatum.

METHODS

Using a prospective observational design, 28 patients were assessed before, 6 weeks and 6 months after a modified Ravitch operation for pectus carinatum. Postoperative pain was assessed using the Short Form McGill Pain Questionnaire. Sensory testing was conducted to detect brush-evoked allodynia and pinprick hyperalgesia. Additionally, generic and disease-specific quality of life was assessed using the Short Form-36 Health Survey and the Nuss Questionnaire Modified for Adults before and after surgery.

RESULTS

Six weeks after surgery, ten patients reported mild pain or discomfort. Six months after surgery, four patients reported only mild pain. Allodynia was detected in two patients 6 weeks and 6 months after surgery. Hyperalgesia was detected in eight patients 6 weeks after surgery, and in six patients 6 months after surgery. Generic quality of life was significantly improved over time.

CONCLUSIONS

The study showed no significant pain problems, a tendency to reduced sensory disturbances and significant improvements in quality of life 6 months after surgical repair of pectus carinatum. Future studies should include a longer follow-up period to determine if these positive results are persistent.

LEVELS OF EVIDENCE

1 (Prognosis Study).

The effect on cardiopulmonary function after thoracoplasty in pectus carinatum: a systematic literature review

OBJECTIVES

Creating an aesthetically appealing result using thoracoplasty, especially when correcting extensive deformities, but only causing low morbidity, is challenging. The frequency of thoracoplasties in cases of pectus carinatum (PC) has increased due to improved experience and modified surgical techniques, resulting in low morbidity and low complication rates. The indications for surgical treatment are still controversial and, in most cases, remain aesthetic or psychological rather than physiological. However, whether cardiopulmonary function changes after surgical repair remains a matter of controversy. We sought to investigate and shed light on published knowledge regarding this question.

METHODS

We searched MEDLINE and PubMed databases, using various defined search phrases and inclusion criteria, to identify articles on pre- and postoperative cardiopulmonary evaluation and outcomes.

RESULTS

Six studies met the inclusion criteria: 5 studies evaluated patients with PC for cardiopulmonary outcomes after chest wall surgery and 1 did so following conservative compression treatment. In these studies, surgical and conservative correction of PC did not reduce absolute lung volumes and spirometric measurements and consequently had no pathogenic effect on cardiopulmonary function.

CONCLUSIONS

The results of this systematic review suggest that surgical correction of PC has no symptomatic pathogenic effect on cardiopulmonary function. The results, however, revealed both heterogeneity in the examinations used and inconsistent methods within each study. Further prospective trials with a stronger methodological design are necessary to objectively confirm that surgical correction of PC does not impair cardiopulmonary function.