Ann Thorac Surg 2007;84:647-648
© 2007 The Society of Thoracic Surgeons
Case Reports
Modified Ravitch Procedure: Using a Pectus Bar for Posttraumatic Pectus Excavatum
Hyun Koo Kim, MD, PhD,
Young Ho Choi, MD, PhD*,
Jae Hoon Shim, MD,
Man-Jong Baek, MD, PhD,
Young-Sang Sohn, MD, PhD,
Hark Jei Kim, MD, PhD
Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University Medical Center, Seoul, Korea
Accepted for publication March 19, 2007.
* Address correspondence to Dr Choi, 97 Guro-Dong, Guro-Ku, Seoul, 152-703, Korea (Email: kughcs{at}korea.ac.kr).
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Abstract
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Guidelines for surgical management of posttraumatic pectus excavatum have not been established due to the variable clinical manifestations and limited number of cases. A 34-year-old man who was involved in a truck-mixer vehicle crash 6 months previously complained of a depressed anterior chest wall deformity. The patient had successfully undergone subperichondral resection, sternal osteotomy, and pectus bar insertion placed under the depressed sternum, followed by bar rotation for elevation of the chest wall. This case illustrates that a modified Ravitch procedure, using a pectus bar, may be an alternative for posttraumatic pectus excavatum.
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Introduction
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Acquired chest wall deformities constitute less than 1% of all thoracic deformities [1]. Although posttraumatic pectus excavatum resulting from direct injury to the chest was reported as early as 1931 [2], there has been little interest in this problem with few published reports available in the medical literature. In addition, because of the variable presentation, there are no treatment guidelines available for patient treatment. Recently we successfully treated a patient with posttraumatic pectus excavatum who underwent a modified Ravitch procedure using a pectus bar.
A 34-year-old man was involved in a truck crash 6 months previously. He suffered from multiple fractures of the ribs bilaterally as well as a bilateral hemopneumothorax. Respiratory failure necessitated tracheostomy with mechanical ventilation for several weeks and a longstanding indwelling central catheter, which resulted in thrombotic occlusion of the innominate vein for which percutaneous angioplasty with stent placement was carried out. The patient was seen in consultation 6 months post-injury. He complained of a depressed anterior chest wall deformity, intense chest wall pain, and dyspnea on exertion. His symptoms significantly limited his daily activities and he was unhappy with his appearance.
A chest roentgenogram and computed tomographic scan were obtained that demonstrated asymmetric depression of the sternum from the second to the fifth costal cartilages and intrusion of the end of the left fourth costal cartilage into the lung parenchyma (Fig 1). The pectus index was 3.20. Pulmonary function testing showed mildly restrictive lung volumes (forced vital capacity of 3.35 L [76%] and forced expiratory volume in 1 second of 2.53 [72%]).
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Fig 1. Preoperative chest roentgenograms (A, posterolateral view; B, left lateral view) showed depression of the sternum and an old fracture of the bilateral ribs.
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The patient was placed in the supine position and general anesthesia was induced. A chevron infra-mammary incision was made. The pectoralis muscles were detached from the sternum and retracted forward and laterally, and the abdominal muscles were mobilized inferiorly to expose the deformed costal cartilages. Subperichondral resection of the second through the fifth costal cartilages was achieved by incising the perichondrium anteriorly. The costal cartilages were partially excised, preserving a margin on the rib to protect the costochondral junction and the longitudinal growth plate. Sternal osteotomies were created over the level of the second and fourth cartilages and closed with several steel wire sutures as the sternum was elevated. A 330-mm pectus bar (MX-bar system [Medix Align Technology, Seoul, Korea]) was bent into a convex shape conforming to the desired curvature of the thoracic cavity anteriorly. The bar was passed across the mediastinum under the depressed sternum and then rotated 180° to elevate the chest wall depression. Both ends and hinge points of the bar were firmly fixed to the ribs by pericostal steel wire sutures (Fig 2). The patient remained in the intensive care unit for a day and was discharged on postoperative day 9 uneventfully. At the 14-month follow-up, the pectus index was improved to 2.97 by chest computed tomographic scan, and pulmonary function testing was similar to the preoperative findings (forced vital capacity of 3.45 L [80%], forced expiratory volume in 1 second of 2.69 [75%]). Currently, the patient still has the bar in place (Fig 3) and is very happy with his appearance.
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Fig 2. Subperichondral resection of the second through fifth costal cartilages and the sternal osteotomies were closed with steel wire sutures. A convex shaped-pectus bar was passed across the mediastinum under the sternum.
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Fig 3. The chest roentgenograms at postoperative 14 months (A, posterolateral view; B, left lateral view) showed that the pectus bar supported the anterior chest wall.
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Comment
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Posttraumatic pectus excavatum is unusual; there are very few reports on this topic in the medical literature. Fokin and Robicsek [1] reported on 1 patient with asymmetric posttraumatic carinatum who had achieved satisfactory correction of the deformity with stabilization of the chest by resection and suturing of the affected cartilages.
Thin metallic struts, developed by Adkin and Blades [3], have been effectively used in patients with connective tissue disorders, advanced age, and severe asymmetric chest wall deformity. The costal cartilages, as well as the sternum, were elevated by the struts to obtain optimal chest contour and reattachment of the costal cartilages to the sternum. Fonkalsrud [4] and Fonkalsrud and Anselmo [5] reported that internal sternal support, with a temporary metal bar or prosthesis, after repair of pectus excavatum or carinatum was found to minimize the occurrence of postoperative respiratory distress caused by paradoxical chest wall motion, reduce pain, permit early ambulation and deeper respirations, as well as reduce hospitalization and cost, and maximize the extent to which the defect was permanently corrected.
In the case reported here, the surgeons chose a strong and potentially longstanding sternal and perichondreal support postoperatively considering the patient’s age and posttrauma status. The Nuss procedure [6] developed in 1988 has been widely used by many surgeons. Although some surgeons have expressed caution in the application of this procedure in patients with connective tissue diseases, eccentric deformities, and advanced age [7], the pectus bar had enough force to elevate the anterior chest wall, which was more powerful than a strut. Therefore we used the pectus bar instead of a strut for this patient. The patient did not need any artificial ventilation postoperatively, could walk on postoperative day 3, and could be discharged early. The modified Ravitch procedure, using a pectus bar, may be a good treatment option for posttraumatic pectus excavatum.
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References
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- Fokin AA, Robicsek F. Acquired deformities of the anterior chest wall Thorac Cardiovasc Surg 2006;54:57-69.[Medline]
- Alexander J. Traumatic pectus excavatum Ann Surg 1931;93:489-500.[Medline]
- Adkins PC, Blades B. A stainless steel strut for correction of pectus excavatum Surg Gynecol Obstet 1961;113:111-113.[Medline]
- Fonkalsrud EW. Current management of pectus excavatum World J Surg 2003;27:502-508.[Medline]
- Fonkalsrud EW, Anselmo DM. Less extensive techniques for repair of pectus carinatum: the undertreated chest deformity J Am Coll Surg 2004;198:898-905.[Medline]
- Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum J Pediatric Surg 1988;33:545-552.
- Molik KA, Engum SA, Rescorla FJ, et al. Pectus excavatum repair: experience with standard and minimal invasive techniques J Pediatric Surg 2001;36:324-328.[Medline]
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Abstract
Introduction
