Medical Care
Most motivated patients with pectus carinatum, especially those younger than 18 years with malleable chest walls, benefit from orthotic bracing, and this is generally the first line of therapy. [18, 19] Success rates of 65-80 % and long-term outcomes with orthotic bracing alone are encouraging. [12]
A study by Lee at el (2012) describes the preliminary results of 98 children treated using the Calgary Protocol, which involves a self-adjustable, low-profile bracing system used in 2 phases. The first phase involves 24 h/d bracing until correction is achieved. The second phase is a maintenance phase during which the brace is worn only at night until axial growth is complete. Twenty-three children completed treatment with good patient satisfaction and improved appearance, suggesting that when used in this fashion, it is an effective treatment for pectus carinatum. Therapy failed in 42 children, owing to either noncompliance or they were lost to follow-up. Two required surgical intervention after bracing failed to correct the problem. Additional studies and follow-up of the children still on protocol is important. [20]
A study by Wahba et al reported that less intensive bracing (< 12h/day) is associated with higher patient compliance (89.6% vs. 81.1%) with a similar time to correction (7.3 vs 7.1 months) and success rate (85.3% vs. 83.5%) when compared to more intensive bracing (≥12h/day). [21]
For older patients with more rigid chest walls, bracing may not be effective and surgery may be the initial consideration.
Casting followed by bracing or bracing alone eliminates the risks of surgery and anesthesia and does not preclude surgery if unsuccessful.
Surgical Care
Endoscopic resection of costal cartilage with a sternal osteotomy
Because many corrections are performed for cosmetic reasons, decreasing the size of incisions is important.
In 1997, Kobayashi reported 2 patients in whom the pectus carinatum deformity was corrected with limited incisions using an endoscopic approach. [20] They suggest that this approach is better indicated in preschool-aged children because of their skin quality and tone, as well because of the increased ease of costal dissection compared with adult patients.
In 2008, Fonkalsrud reported a series of 260 patients who underwent surgical correction of pectus carinatum deformities over a period of 37 years. [4] He concluded that, over time, the trend towards less extensive open techniques has resulted in "low morbidity, mild pain, short hospital stay and very good physiologic and cosmetic results." His study included both pediatric and adult patients.
Open surgical repair
Various methods have been described. The reader is referred to Del Frari and Schwabegger (2011) [22] and Cohee et al (2013) [23] for further details.
Minimal access repair
A comparative analysis of 12 different surgical techniques for minimal access repair was published by Muntean et al. [24]
Consultations
Pectus carinatum has been associated with congenital heart disease. In these patients, and in those with suspected or identified cardiac pathology, preoperative cardiology evaluation is recommended.
Exercise testing may be performed in consultation with either a cardiologist or a pulmonologist.
Symptomatic patients with exertional dyspnea, tachypnea, or decreased endurance, as well as those with asthma symptoms, benefit from a pulmonology evaluation.
Individuals with pectus carinatum who have significant concerns about their body image or low self-esteem can benefit from psychological counseling.
Activity
Symptomatic patients may report decreased exercise tolerance and exertional dyspnea, which may limit activity. Fonkalsrud's series (2008) reported improvement in exertional symptoms and endurance in all symptomatic patients within 3-6 months of surgical repair. [4]
Fonkalsrud's recommendations for postoperative activity include the following [4] :
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Use incentive spirometer and encourage periodic deep breaths.
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Limit twisting movements of the chest for at least 4 months postoperatively.
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Avoid rapid elevation of the arms overhead for at least 4 months postoperatively.
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Encourage lower extremity exercise (may begin within first 2 wk after surgery).
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Light weights may be used to strengthen biceps and deltoids; the use of chest and abdominal muscles may be increased later (after 3-4 wk).
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Gym classes are not indicated for 5 months after surgery in school-aged children.
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Long-term recommendations include stretching exercises that involve pulling the shoulder blades posteriorly to improve posture.
Complications
Complications vary according to treatment selection.
Ill-fitting braces can be associated with skin irritation and skin breakdown.
Shamberger reported a 3.9% complication rate with open surgical repair. [25] Complications include pneumothorax (2.6%), wound infection (0.7%), atelectasis (0.7%), and local tissue necrosis (0.7%). The mean postoperative stay was 5.8 days.
Fonkalsrud (2008) reported shorter hospital stays (mean, 2.6 d), mild postoperative pain, and low complication rate with limited resection and immediate chest stabilization. [4]
Also see Complications in the Presentation section.
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Pectus carinatum. Photograph courtesy of K. Kenigsberg, MD.
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Chest radiograph of a patient with pectus carinatum. Radiograph courtesy of A. Fruauff, MD.
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CT scan of a patient with pectus carinatum. CT courtesy of A. Fruauff, MD.
