Brace compression for treatment of pectus carinatum

Psychometric properties of the Turkish version of the Pectus Carinatum Evaluation Questionnaire used in patients with pectus carinatum treated with compression orthosis

BACKGROUND

The Pectus Carinatum Evaluation Questionnaire (PCEQ) was developed for use in patients with pectus carinatum (PC) treated with compression orthosis. The questionnaire can be used to develop a strict program in the early follow-up period or to improve patients' compliance with the treatment after treatment initiation and to improve the quality of life.

OBJECTIVE

This study aimed to evaluate the psychometric properties of the Turkish version of the PCEQ in patients with PC treated with compression orthosis.

STUDY DESIGN

Validity and reliability study.

METHODS

This study included 52 volunteer patients with PC, aged 10-18 years. The Cronbach α coefficient, a measure of internal consistency, was used to check questionnaire reliability, and test-retest reliability (intraclass correlation coefficient) was used to check consistency over time. Construct validity was analyzed (correlation analysis) with the days/hours of orthosis use.

RESULTS

The reliability of the Turkish version of the PCEQ was found to have acceptable-to-sufficient-to-excellent internal consistency (Cronbach α coefficient = 0.701-915). Test-retest reliability calculated for investigating the reliability of the questionnaire over time was found to be excellent (intraclass correlation coefficient = 0.880-0.941). Furthermore, treatment compliance hours (r = 0.280, P = 0.044) and days (r = 0.299, P = 0.032) were found to be associated with parents' influence at a low level and with time to compliance at a moderate level (r = -0.449-457, P = 0.001).

CONCLUSION

The Turkish version of the PCEQ used in patients with PC treated with compression orthosis was found to have sufficient-to-excellent validity and reliability and could be used to develop a strict program for patients with PC using the orthosis or to improve patients' treatment compliance after treatment initiation. Using this questionnaire may be important to assist the team members in the clinical decision-making process.

Minimally invasive repair of pectus carinatum by the Abramson method: A systematic review

BACKGROUND

The aim of this review is to provide an overview of the outcomes after minimally invasive pectus cartinatum repair (MIRPC) by the Abramson method to determine its effectiveness.

METHODS

The PubMed and Embase databases were systematically searched. Data concerning subjective postoperative esthetic outcomes after initial surgery and bar removal were extracted. In addition, data on recurrence, complications, operative times, blood loss, post-operative pain, length of hospital stay, planned time to bar removal and reasons for early bar removal were extracted. The postoperative esthetic result, was selected as primary outcome since the primary indication for repair in pectus carinatum is of cosmetic nature.

RESULTS

Six cohort studies were included based on eligibility criteria, enrolling a total of 396 patients. Qualitative synthesis showed excellent to satisfactory esthetic results in nearly all patients after correctional bar placement (99.5%, n = 183/184). A high satisfaction rate of 91.0% (n = 190/209) was found in patients after bar removal. Recurrence rates were low with an incidence of 3.0% (n = 5/168). The cumulative postoperative complication rate was 26.5% (n = 105/396), of whom 25% required surgical re-intervention. There were no cases of mortality.

CONCLUSIONS

Minimally invasive repair of pectus carinatum through the Abramson method is effective and safe. Its efficacy is demonstrated by the excellent to satisfactory esthetic results in 99.5% and 91.0% of patients after respectively correctional bar placement and implant removal. Future studies should aim to compare different treatment options for pectus carinatum in order to elucidate the approach of choice for different patient groups.

Seasonal interest in pectus excavatum and pectus carinatum: a retrospective analysis of Google Trends data

Background

Individuals affected by chest wall deformities may search for information on these conditions on the web. Google data may reflect the global interest in health-related information. Our aim was to investigate the global trends in searches associated with the topics “Pectus excavatum” and “Pectus carinatum” using Google Trends.

Methods

We retrieved the global data from 1st January 2004 to 31st October 2019. We analyzed the relative search volume (RSV) for countries or areas with a no-low search volume. We compared differences in interest between seasons using the Kruskal-Wallis test with the post-hoc test.

Results

The median RSV for the pectus excavatum was equal to 58.00 (54.00–65.00) while for pectus carinatum 28.00 (23.25–31.00). The interest in pectus excavatum decreases on average by 0.98 RSV each year, while interest in pectus carinatum increased each year by 0.87 RSV. We observed the highest interest in analyzed topics during summer and the lowest during winter. The relative difference in interest between summer and winter was equal to 21.4% for pectus excavatum and 19.2% for pectus carinatum. Pectus excavatum was the most popular topic in n=51 countries or areas, while pectus carinatum in n=7 countries or areas/regions.

Conclusions

Globally, interest in pectus excavatum is higher than the interest in pectus carinatum that might reflect real-world prevalence. The interest in both topics shows seasonal variation. The Internet is an essential source of information on chest wall deformities. The medical professionals should provide quality content on pectus excavatum and pectus carinatum.

Usefulness of 3-Dimensional Body Surface Scanning in the Evaluation of Patients with Pectus Carinatum

Background

Radiographic modalities have been commonly used to evaluate pectus carinatum (PC), and compressive orthotic bracing is the most widely accepted treatment method. The aim of this study was to determine the efficacy of 3-dimensional (3D) body surface scanning as an alternative modality for the evaluation of PC.

Methods

The medical records of 63 patients with PC who were treated with compressive orthotic bracing therapy between July 2017 and February 2019 were retrospectively analyzed. Using both 2-view chest radiography (posteroanterior and lateral view) and 3D body scanning, the height of maximal protrusion of the chest wall was measured both before and after 2 weeks of bracing therapy. The difference between the pre- and post-treatment measurements was calculated for both modalities, and these differences were compared and analyzed.

Results

Based on the comparison between the pre- and post-treatment radiographs, bracing therapy produced favorable outcomes in all patients (p<0.001). The measurements obtained via 3D scanning were strongly correlated with those obtained via chest radiography (r=0.60).

Conclusion

Based on the findings of this study, 3D body surface scanning appears to be an effective, radiation-free, and simple method for the post-treatment follow-up evaluation of PC, and thus can be considered an alternative to radiography.

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.

Does physiotherapy applied in conjunction with compression brace treatment in patients with pectus carinatum have efficacy? A preliminary randomized-controlled study

PURPOSE

Non-invasive treatment of pectus carinatum (PC) deformity includes the use of a compression brace and exercises. In this study, we aimed to examine the effect of a physiotherapy protocol applied as adjunct to compression brace treatment in patients with PC.

METHODS

The study included 30 male patients between 11 and 18 years of age. Patients were randomly assigned into two groups: a brace treatment only group (Group 1) and a brace and physiotherapy group (Group 2). Patient demographics and disease-related properties, protrusion measurements, postural evaluations, deformity perceptions, life quality, and treatment satisfaction were evaluated.

RESULTS

Although both groups showed improvements based on external chest measurements related to PC protrusion following treatment (p < 0.001), Group 2 had more benefit from the treatment (effect size > 0.36) and displayed greater improvement in maximum protrusion degree and lateral length values (p < 0.05). Additionally, we found that patient perception of deformity, posture, psychological life quality, and treatment satisfaction scores were significantly better in Group 2 (p < 0.05).

CONCLUSION

Owing to the satisfaction and additional benefits observed in the physiotherapy group, we think that a proper cardiopulmonary and musculoskeletal exercise program should be applied concurrently with brace treatment for patients with PC deformity. Nevertheless, long-term outcomes need to be clarified in future studies.

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.

Pectus carinatum: When less is more

Awareness of pectus carinatum has increased among the medical community over the last several decades, as innovative options for nonsurgical treatments have become more widely known. Management alternatives have shifted from open resective to minimally invasive strategies, and finally, to reshaping the chest using both surgical and non-surgical modalities. We aim to review the evolution of the diagnosis and treatment of pectus carinatum up to its current management.

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 less intensive bracing protocol for pectus carinatum

OBJECTIVES

Despite the widespread use of bracing to correct Pectus carinatum (PC) there is no consensus in the number of hours per day patients are instructed to wear the brace. In our practice, we use a less rigorous protocol of 8-12h/day. We sought to evaluate our results and those in the literature to determine whether more intensive usage is necessary.

STUDY DESIGN

We reviewed the outcomes of patients with PC treated at our institution between 2012 and 2015. We searched MEDLINE, EMBASE and Web of Science for studies describing the use of bracing to correct PC.

RESULTS

Seventy-five patients presented with PC at our institution. Among those who were offered bracing and had adequate follow-up (n=32), the success rate (full correction or improvement) was 90.6%. The compliance rate was 93.8%. Fifteen studies met our inclusion criteria. Our pooled data combining our results with those of other published data showed that less intensive brace usage (<12h/day), when compared to more intensive usage (≥12h/day), is associated with higher patient compliance (89.6% vs. 81.1%) with a similar time to correction (7.3 vs 7.1months) and success rate (85.3% vs. 83.5%).

CONCLUSIONS

Implementing a less intensive bracing protocol for PC is successful, efficient and improves compliance.

TYPE OF STUDY

Clinical Research.

LEVELS OF EVIDENCE

Oxford Centre for Evidence-Based Medicine Level-of-Evidence rating: Level IV.

The Dynamic Compression Brace for Pectus Carinatum: Intermediate Results in 286 Patients

BACKGROUND

Dynamic brace compression is a novel treatment for patients with pectus carinatum. The dynamic compression system contains a device to measure the flexibility of the thoracic wall and regulate the pressure of the brace.

METHODS

Patients referred to our pediatric surgical center were screened for treatment with the dynamic compression brace. Patients with a pressure of initial correction (PIC) of 10.0 pounds per square inch or less were offered treatment with the brace. Patients with a PIC above 10.0 pounds per square inch were offered surgical correction. Between March 2013 and April 2016, 286 patients were treated with the brace; 260 were male (91%) and 26 were female (9%). Their mean age was 14 years (range, 4 to 21 years).

RESULTS

Seventy-eight patients completed brace treatment; the mean treatment time was 14 months. Twenty-seven patients abandoned treatment because of lack of motivation, loss to follow-up, persistent protrusion of the sternal bone or flaring that required surgical correction, failure of treatment because of a bifid rib, fear of locking the brace, and delayed correction. One hundred eighty-one patients are still wearing the brace, either in the active or in the retainer phase. Patients with a high PIC also showed improvement when they were compliant. Adverse events were minor and included skin lesions (n = 4, 1%) and vasovagal reactions at the start of therapy (n = 3, 1%).

CONCLUSIONS

These data show that brace therapy can be considered a valuable treatment option to correct pectus carinatum in patients with a flexible thorax.

Success and duration of dynamic bracing for pectus carinatum: A four-year prospective study

BACKGROUND

This study sought to establish factors that can prognosticate outcomes of bracing for pectus carinatum (PC).

METHODS

Prospective data were collected on all patients enrolled in a dynamic bracing protocol from July 2011 to July 2015. Pressure of correction (POC) was measured at initiation of treatment, and pressure of treatment (POT) was measured pre- and post-adjustment at every follow-up visit. Univariate and Cox regression analysis tested the following possible determinants of success and bracing duration: age, sex, symmetry, POC, and POT drop during the first two follow-up visits.

RESULTS

Of 114 patients, 64 (56%) succeeded, 33 (29%) were still in active bracing, and 17 (15%) failed or were lost to follow-up. In successful patients, active and maintenance bracing was 5.66±3.81 and 8.80±3.94months, respectively. Asymmetry and older age were significantly associated with failure. Multivariable Cox proportional hazard analysis of time-to-maintenance showed that asymmetry (p=0.01) and smaller first drop in POT (p=0.02) were associated with longer time to reach maintenance.

CONCLUSIONS

Pressure of correction does not predict failure of bracing, but older age, asymmetry, and smaller first drop in pressure of treatment are associated with failure and longer bracing duration.

LEVEL OF EVIDENCE

Prospective Study/Level of Evidence IV.

Is the Abramson technique effective in pectus carinatum repair?

BACKGROUND

The minimally invasive pectus carinatum (PC) surgery described by Abramson has been performed in many centers. We have been using this technique since 2011. This article describes our experience with PC correction.

METHODS

Between 2011 and 2016, 32 patients at our institution underwent minimally invasive repair of a PC deformity. All patients presented with cosmetic complaints. The deformity involved the lower sternum (all had chondrogladiolar type PC), and three patients had asymmetrical deformities. All operations followed the principles defined by Abramson.

RESULTS

Satisfactory esthetic results were achieved in our patients. The hospital stay averaged 5.3 days (range 4-7 days). The most common early complication was pneumothorax, and the most common late complication was wire suture breakage.

CONCLUSION

The Abramson technique is an effective, minimally invasive procedure for PC with shorter operating and hospitalization times and low morbidity rates.

Pectus Carinatum Evaluation Questionnaire (PCEQ): a novel tool to improve the follow-up in patients treated with brace compression

OBJECTIVES

A questionnaire (Pectus Carinatum Evaluation Questionnaire, PCEQ) was developed to be applied in follow-up of patients with Pectus Carinatum (PC). After validation of the PCEQ, we aimed to quantify the compliance to brace compression and to assess factors that could influence this treatment in patients with PC.

METHODS

From July 2008 to July 2014, 56 patients with PC were treated with the Calgary Protocol of compressive bracing at Paediatric Surgery Department of Hospital São João. Forty patients (71%) completed the questionnaire. The PCEQ was divided into four sections: (i) compliance; (ii) symptoms; (iii) social influence; (iv) activities. For the validation process of the PCEQ, principal components analysis (PCA), orthogonal varimax or oblimin rotation and Cronbach's α coefficient were used. To evaluate the association between compliance and other sections of the questionnaire, we estimated the Pearson's correlation between compliance factor scores ('Compliance Days' and 'Compliance Hours') and the final score of each new questionnaire component identified by PCA ('Chest Pain', 'Dyspnoea', 'Back Pain', 'Parents' Influence', 'Friends' Influence', 'Activities', 'Time To Compliance'). For the sections 'Symptoms', 'Social Influence' and 'Activities', we estimated final scores as the sum of the questions that constitute each component. For the section 'Compliance', the factor scores were estimated by the regression method.

RESULTS

After PCA analysis, the PCEQ found nine different components with high reliability. When analysing the compliance of our study group, the final score for 'Activities' revealed a significant correlation with the factor score for 'Compliance Hours' (r = 0.382, P = 0.015). The final score for 'Time To Compliance' showed a significant correlation with both factor scores for 'Compliance Hours' (r = -0.765, P < 0.001) and 'Compliance Days' (r = -0.345, P < 0.029).

CONCLUSIONS

The PCEQ seems to be an important tool to follow up patients with PC treated by brace compression. Practical steps, such as developing a tight schedule in the early follow-up period or applying the PCEQ in first visits after initiating brace therapy, can be taken in order to increase compliance with brace therapy and improve the quality of life.