Ann Thorac Surg 2008;85:1100-1101. doi:10.1016/j.athoracsur.2007.09.018
© 2008 The Society of Thoracic Surgeons
Case Reports
Sternal Plating to Correct an Unusual Complication of the Nuss Procedure: Erosion of a Pectus Bar Through the Sternum
Gary W. Raff, MDa,*,
Michael S. Wong, MDb
a Division of Pediatric Cardiac Surgery, University of California San Francisco, San Francisco, California
b Divisions of Cardiothoracic Surgery, and Plastic and Reconstructive Surgery, University of California Davis, Sacramento, California
Accepted for publication September 11, 2007.
* Address correspondence to Dr Raff, University of California San Francisco, Pediatric Cardiac Surgery, Box 0117, 513 Parnassus Ave, San Francisco, CA 94143 (Email: raffg{at}surgery.ucsf.edu).
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Abstract
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We present erosion of a pectus bar through the sternum in a patient with Marfan syndrome. The complication as well as a novel technique for sternal reconstruction are reviewed.
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Introduction
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The Nuss procedure is a fairly new technique first reported in 1990 to address pectus excavatum without removal or incisions into the costal cartilages. The patient population that is best served by this versus the Ravitch procedure is unknown. Although most patients have a satisfactory result, there may be populations at increased risk of complications or suboptimal result with the Nuss procedure.
We present an unusual complication of the Nuss procedure [1]. The patient was a 21-year-old woman with Marfan syndrome. She underwent a modified Ravitch procedure at age 10 that significantly worsened after a motor vehicle accident at age 20. She complained of chronic chest pain that prevented her from working. She underwent Nuss repair with two bars (Pectus Bar; W. Lorenz Surgical, Jacksonville, FL) and initially had a good result with improvement of pain symptoms. At 8 weeks, her pain worsened. Chest radiograph noted buckling of the sternum (Fig 1). At 12 weeks, she had continued worsening of pain over her sternum. The superior bar was easily palpable on either side of the sternum, with increased tenderness over the sternum. Chest radiograph confirmed erosion of the bar anteriorly (Fig 2). She was taken to the operating room for sternal reconstruction.
Under general anesthesia, the Nuss repair incisions were reopened. The bars and stabilizers were well incorporated. The stabilizers were removed, followed by the bars, and the wounds closed. A midline incision was made over the sternum. Bilateral submuscular flaps were raised, exposing the sternum and costal cartilages. A pseudoarthrosis created by the erosion of the superior pectus bar was noted. In addition, the sternum was rotated leftward. The sternum was mobilized. The fibrous tract previously containing the superior Nuss bar was opened, the pseudoarthrosis excised, and bone graft was placed along this area. A wedge osteotomy was made through the anterior table of the sternum and stabilized with an an X-plate (SternaLock; W. Lorenz Surgical [Fig 3]). The remaining sternum was rotated and supported with two Adkins Struts (Baxter Healthcare Corp, McGraw Park, IL) and stainless steel wire, correcting the rotational deformity of the sternum. The xiphoid was reattached. Drains were placed, and a layered skin closure was performed.
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Fig 3. (1) Wedge osteotomy point of erosion (arrow), (2) sternal plate in place with posterior supporting strut inferiorly.
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Comment
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Factors that may have contributed to this complication include Marfan syndrome, older age at operation, previous Ravitch procedure, and injury to the sternum from the pectus bar. As application of the Nuss procedure becomes more widespread, an increase in recognition of rare complications has occurred [2–4]. This is the first detailed report of erosion of a pectus bar through the sternum. There is brief mention of one other case as part of an early report of the Nuss procedure [4]. In this review, the incidence was 0.4% (1 patient). Patients with connective tissue disorders may be at higher risk depending on age at time of surgery and type of stabilization used [5]. The largest series of surgery for failed pectus repair utilizing the Nuss procedure described 50 patients (1 patient with Marfan syndrome) [6]. The overall incidence of complications was slightly higher than for primary Nuss repair. The impact of connective tissue disease on complications after Nuss repair has not been well described. Clinicians should exercise caution in utilizing the Nuss procedure in these patients. Prolonged need for narcotics, increasing tenderness along the sternum, and lateral chest radiographs demonstrating buckling of the sternum warrant close follow-up and a low threshold for early bar removal.
Previous reports describe malpositioning of the pectus bar as a risk factor for early bar displacement [6]. It is possible that the bar was placed in an area of previous fracture or weakness from the prior pectus repair or her motor vehicle accident. There is evidence the pectus bar causes alterations in the sternum detectable using bone scintigraphy [7]. Some of these changes are consistant with sternal microfractures at the site of the pectus bar. These microfractures of the sternum may explain the increased symptoms of pain in older patients after the Nuss procedure.
In contrast to the Ravitch procedure, the Nuss procedure has limited ability to assess sternal integrity. In cases where reoperation has failed, innovative solutions are often necessary. Rigid fixation using plates specifically designed for sternal fixation has shown excellent results [8]. Use of tools such as these can allow for solutions to complex problems and complications of sternal reconstruction (Fig 4).
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Fig 4. The left image demonstrates contour irregularities present after failure of her Nuss procedure while the right demonstrates improved chest contour after modified Ravitch procedure with sternal plate fixation.
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References
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- Nuss D, Kelly Jr RE, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum J Pediatr Surg 1998;33:545-552.[Medline]
- Shin S, Goretsky MJ, Kelly Jr RE, Gustin T, Nuss D. Infectious complications after the Nuss repair in a series of 863 patients J Pediatr Surg 2007;42:87-92.[Medline]
- Hoel TN, Rein KA, Svennevig JL. A life-threatening complication of the Nuss procedure for pectus excavatum Ann Thorac Surg 2006;81:370-372.[Abstract/Free Full Text]
- Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases J Pediatr Surg 2000;35:252-258.[Medline]
- Arn PH, Scherer LR, Haller Jr JA, Pyeritz RE. Outcome of pectus excavatum in patients with Marfan syndrome and in the general population J Pediatr 1989;115:954-958.[Medline]
- Croitoru DP, Kelly Jr RE, Goretsky MJ, Gustin T, Keever R, Nuss D. The minimally invasive Nuss technique for recurrent or failed pectus excavatum repair in 50 patients J Pediatr Surg 2005;40:181-187.[Medline]
- Ohno K, Morotomi Y, Harumoto K, et al. Preliminary study on the effects of bar placement on the thorax after the nuss procedure for pectus excavatum using bone scintigraphy Eur J Pediatr Surg 2006;16:155-159.[Medline]
- Song DH, Lohman RF, Renucci JD, Jeevanandam V, Raman J. Primary sternal plating in high-risk patients prevents mediastinitis Eur J Cardiothorac Surg 2004;26:367-372.[Abstract/Free Full Text]
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Abstract
Introduction
