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.

Simultaneous Bilateral Thoracoscopy During the Nuss Procedure is Safe, Effective and Allows for Optimal Visualization of the Bar Passer Throughout the Substernal Dissection.

PURPOSE: Cardiac injury during the Nuss procedure is a rare risk that can lead to a catastrophic outcome. The specific aim of this pilot study was to evaluate the safety and efficacy of simultaneous bilateral thoracoscopy (SBT) compared to standard unilateral right thoracoscopy (RT) in children undergoing the Nuss procedure in order to mitigate that risk. METHODS: IRB approval was obtained to analyze data on children who underwent SBT and RT during the Nuss procedure. Data retrieval included age, gender, Haller index (HI), operative time (OT), length of stay (LOS), complications and follow up. RESULTS: From August 2022 to August 2023, 10 children who underwent SBT were compared to 10 children who underwent RT. Both groups underwent intercostal nerve cryoablation. Following completion of cryoablation, SBT or RT was carried out during the Nuss procedure. SBT allowed for the tip of the bar passer to be visualized during the entire dissection in both thoraces. There was no significant difference in either group with respect to age, HI, OT, LOS. There were no anesthetic or surgical complications in either group. CONCLUSION: We found that SBT is safe, effective and allows for 100% visualization of the tip of the bar passer during the entire critical phase of the Nuss procedure. It does not impact OT or LOS compared to children who underwent only RT. SBT may benefit children who undergo the Nuss procedure by reducing the risk of cardiac injury. TYPE OF STUDY: Original Research Retrospective Case-control study.

One- versus Two-Minute Intercostal Nerve Cryoanalgesia in Children Undergoing Surgery for Funnel Chest Deformity.

An inherent defect of the sternum and ribs results in the formation of a funnel-shaped anterior chest wall. The gold standard of surgical correction is the minimally invasive Nuss procedure, which might cause severe pain and carries the risk of sensory disturbances and chronic discomfort. Integrating cryoanalgesia with standard multimodal analgesia improves the outcomes of this procedure. Based on histological results, it was hypothesised that the time of cryo-application can be reduced from the current standard period of two minutes. The goal of this study was to evaluate the efficacy of a one-minute application compared with the routine two-minute method in the same patient, considering the subjective perception of pain and sensory disturbances. A total of 33 patients were included in this prospective study. The results show that the assessment of pain severity and sensory disturbances did not differ significantly in terms of the time of cryo-application during first 14 days after the surgical procedure. The one-minute cryo-application time for intraoperative intercostal nerve cryoablation prior to the Nuss procedure seems to be as safe and effective as the routinely used two-minute application time in regards to pain severity, sensory disturbances, and the risk of chronic pain development. Intercostal nerve cryoanalgesia is an essential element of multimodal analgesia.

Proposing the Retrosternal Angle as a Diagnostic Measure for Banana Sternum in Pectus Excavatum.

BACKGROUND/PURPOSE: Anteriorly convex sternum in pectus excavatum, also known as banana sternum (BS), influences decision-making during repair and, especially, the need to cross bars. However, the definition of BS remains subjective. Thus, we aim to propose the retrosternal angle (RSA) as a diagnostic measure for the discrimination of BS. MATERIAL AND METHODS: Retrospective analysis of a cohort of patients who underwent a minimally invasive repair of pectus excavatum (MIRPE) between October 2016 and October 2023 at our Pectus Clinic. Five expert thoracic surgeons individually reviewed their medical photographs and chest CT scans assigning patients to BS or non-BS groups based on consensus (≥4 surgeons). RSA measurements were obtained by an independent thoracic surgeon. RESULTS: Among 283 cases analyzed, 50 (18%) were classified as BS and 233 (82%) as non-BS. No significant differences were found between groups in age (p = 0.62), Haller index (p = 0.11), or Correction index (p = 0.58). However, RSA was significantly lower in the BS group (141.2 ± 8.4° vs. 154.5 ± 10.3°, p < 0.0001). Receiver operating characteristic curve analysis revealed RSA as a reliable predictor of BS (AUC 0.85, p < 0.0001), with a threshold of 148.5° demonstrating 80% sensitivity and 77% specificity. Regarding potential clinical implications, 26/50 (52%) of patients defined as BS underwent bar crossing, compared with 45/232 (19%) of those not considered a BS (p < 0.0001). CONCLUSION: This study proposes an objective metric, the Retrosternal Angle, to assess BS in chest CT scans, with a threshold of 148.5° showing high sensitivity and specificity. External validation of this angle and threshold is warranted in future investigations. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: III.

Double-bar technique for the correction of asymmetric pectus excavatum.

Background: Minimally invasive repair of pectus excavatum (MIRPE) improves clinical outcomes and chest wall morphology. However, asymmetry in patients with pectus excavatum (PE) remains as an important issue, even after surgery. Here, we evaluated the benefit of double-bar technique in achieving a symmetric chest wall. Methods: This retrospective study included 79 patients with PE who underwent MIRPE between 2017 and 2021. The patients were divided into the double- or non-double-bar groups. Asymmetric degree (AD) and sternal rotation angle (SRA) were used to assess the severity of asymmetry based on computed tomography (CT) images. The primary outcome was the change in radiologic parameters. Secondary outcomes were clinical results, including hospital stay, pain scores, and complication rates. Subgroup analysis of patients with preoperative asymmetric PE was performed. Results: Patients in the double-bar group (n=23) were younger than those in the non-double-bar group (n=56). Additionally, the double-bar group exhibited lower pain scores and shorter hospital stay. Based on radiological assessments, the double-bar group demonstrated a greater decrease in AD without compromising improvement in the Haller index (HI). The benefit of the double-bar technique was more obvious among patients with asymmetry with a preoperative AD >5%, resulting in a significant reduction in AD. In this subgroup, a better correction of sternal rotation was observed. Conclusions: The double-bar technique may be a promising option for correcting asymmetry in patients with PE. Simplified AD and SRA radiologic assessments can be used to evaluate improvements in chest wall configuration.

Six Years of Quality Improvement in Pectus Excavatum Repair: Implementation of Intercostal Nerve Cryoablation and ERAS Protocols for Patients Undergoing Nuss Procedure.

BACKGROUND: The Nuss procedure for pectus excavatum is associated with prolonged hospitalizations due to pain. We evaluated implementation of intercostal nerve cryoablation and enhanced recovery after surgery (ERAS) protocols on outcomes of Nuss procedures performed over six years at a single institution. METHODS: This retrospective cohort study included patients who underwent Nuss procedure from 10/2017 to 09/2023. Patients received epidurals prior to 06/2019, cryoablation from 06/2019 to 07/2021, and ERAS with cryoablation and intraoperative methadone administration after 07/2021. We used multivariable linear regression to evaluate length of stay (LOS), inpatient morphine milligram equivalents (MMEs), and discharge opioids. We assessed the balancing measures of operative time, postoperative pain scores, and complications. RESULTS: We identified 62 patients; 15 who received epidurals, 18 cryoablation, and 29 cryoablation with ERAS. Cryoablation was associated with a 62.3% (p < 0.001) decrease in length of stay, an 86.6% (p < 0.001) decrease in inpatient MMEs, and a 72.9% (p < 0.001) decrease in discharge opioids. Cryoablation was additionally associated with 24.5% (p = 0.02) longer operative times and 46.4% (p = 0.04) higher postoperative day one pain scores. Subsequent implementation of an ERAS protocol was associated with a further 82.8% (p = 0.04) decrease in discharge opioids and a 25.0% (p = 0.04) decrease in postoperative day one pain scores. CONCLUSIONS: Over six years of quality improvement efforts, we found the implementation of cryoablation and ERAS protocols to be associated with a significant decrease in length of stay and opioid exposures. Protocolized pain management and cryoablation may work synergistically to improve outcomes without compromising patient experience. LEVEL OF EVIDENCE: Level III - Retrospective comparative study.

Patient satisfaction after Nuss procedure with one or two bars in young adults: A propensity score-matched cohort study.

BACKGROUND: The Nuss procedure is the primary treatment for pectus excavatum (PE), but patient expectations are not always met. In our unit, our standard approach in the last few years has been the routine application of two bars instead of one. We aimed to retrospectively assess the impact of this approach on patient satisfaction, quality of life (QoL) and safety. METHODS: A retrospective study included 182 patients over 16 years old who underwent the Nuss procedure for PE between January 2007 and September 2021. Patients were categorized into one-bar or two-bar correction groups. Propensity score matching (PSM) was used, resulting in 30 patients in each group. Primary endpoints were QoL and cosmetic satisfaction, while secondary endpoints included complications and recurrence. RESULTS: After PSM, both groups showed similar general characteristics. Patients treated with two bars reported fewer psychological complaints post-surgery (93.3% vs. 73.3%, p = 0.031). There were no significant differences in QoL improvement (96.7% in both groups, p = 0.197), perioperative complications (p = 0.771) or recurrence (one patient in the one-bar group, p = 1.000). CONCLUSIONS: Our study reveals that patients undergoing the Nuss Procedure for PE with two bars exhibit comparable clinical outcomes and QoL to those with one bar. However, patients with two bars may have higher levels of psychological well-being and satisfaction, indicating potential benefits associated with this approach. These findings suggest potential advantages of the two-bar approach, but further research with larger sample sizes is warranted to confirm these observations.

Bilateral Lung Injury with Delayed Pneumothorax following Preoperative Cryoanalgesia for Pectus Excavatum Repair in a 13-year-old Boy.

A 13-year-old male patient with marfanoid features and pectus excavatum with Haller index 4 and correction index of 38% underwent the Nuss procedure with cryoanalgesia 9 days prior, which transpired uneventfully. Preoperative spirometry was normal, and echocardiogram showed light aortic valve dilation. A month later, during a routine outpatient checkup, he referred middle abdominal pain, denying respiratory symptoms nor thoracic pain. He presented bilateral apical and right basal hypophonesis. Chest X-ray revealed bilateral pneumothorax and right pleural effusion. Consequently, the patient was admitted to the emergency room, and a chest computed tomography was ordered, reporting right apical blebs. Bilateral thoracoscopy was performed, and apexes were checked for pulmonary blebs to rule out primary pneumothorax. In the right chest, a wedge resection of a distorted area on the apex and pleuroabrasion were done. Four air leaking eschars were found when performing lung expansion under water as leaking test, corresponding to cryoanalgesia intercostal eschars, and subsequently closed by primary suture. In the left chest, there were no blebs. However, another four pleural lesions with intact pleura in the left lower lobe were also found. Postoperative course was uneventful and chest drains were removed 48 hours after surgery. He remains asymptomatic 21 months after discharge. Cryoanalgesia in pectus excavatum is spreading due to the improvement in postoperative pain control. However, some complications may occur.

The pectus care guidelines: best practice consensus guidelines from the joint specialist societies SCTS/MF/CWIG/BOA/BAPS for the treatment of patients with pectus abnormalities.

Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care.

Enhanced Recovery After Surgery 2.0: Optimizing Pain Management in Nuss Procedure: Cryoablation and Nerve Block Strategies for Reduced Opioid Use.

INTRODUCTION: Our study assesses the association between cryoablation, with and without nerve block supplementation, post-Nuss procedure pain, and opioid use in pectus excavatum (PE) patients. METHODS: We conducted a retrospective cohort study at a single center for PE patients who underwent the Nuss procedure from 2017 to 2022. Outcomes included postoperative opioid use (measured in oral morphine milligram equivalent per kilogram [OME/kg]), average pain score (scale 0-10), and length of stay (LOS). RESULTS: One hundred sixty-four patients (146 males and 18 females) were included, with 79 (48.2%) receiving neither cryoablation nor nerve block, 60 (36.6%) receiving intraoperative cryoablation alone, and 25 (15.2%) receiving both cryoablation and nerve block. The median age was 16 y. Nerve block recipients consumed fewer opioids during hospitalization than cryoablation alone and nonintervention groups (1.5 versus 2.3 versus 5.8 OME/kg, respectively, P < 0.0001). Average pain scores over the total LOS were lower in nerve block recipients (3.5 versus 3.8 versus 4.2, P = 0.03), particularly on postoperative day 0 (P = 0.002). Nerve block recipients had a shorter LOS than cryoablation alone and nonintervention groups (43.4 versus 54.7 versus 66.2 h, P < 0.0001). On multivariate analysis, cryoablation alone resulted in significantly less opioid use compared to no intervention (3.32 OME/kg reduction, 95% confidence interval -4.16 to -2.47, P < 0.0001). Addition of nerve block further reduced opioid use by 1.10 OME/kg (95% confidence interval -2.07 to -0.14, P = 0.04). CONCLUSIONS: Cryoablation with nerve block supplementation is associated with reduced pain, opioid use, and LOS post-Nuss for PE repair compared to cases without cryoablation or with cryoablation only. Cryoablation with regional nerve blocks should be considered for Nuss repair under the enhanced recovery after surgery pathway.

Analgesic Effectiveness of Truncal Plane Blocks in Patients Undergoing the Nuss Procedure: A Randomized Controlled Trial.

INTRODUCTION: Most patients undergoing the Nuss procedure reported moderate to severe pain after surgery. This study aimed to investigate the efficacy and safety of ultrasound-guided serratus anterior plane block (SAPB) combined with transversus thoracic muscle plane (TTMP) block for relieving acute pain in patients undergoing the Nuss procedure. METHODS: The enrolled patients in our study were allocated to either receive combined nerve blocks with ropivacaine (NB group) or saline (CON group). The primary outcome of this study was postoperative pain at 2, 4, 8, 16, 24, 36, and 48 h during rest and movement (coughing). Secondary outcomes included intraoperative dosage of remifentanil, the time to extubation and the length of stay in the post-anesthesia care unit (PACU), the total acetaminophen and codeine tablet consumption, time to first bowel movement, time to first flatus, opioid-related adverse events, and the length of hospital stay. RESULTS: Patients in the NB group had significantly lower Numerical Rating Scale (NRS) pain scores compared with the CON group. The NB group required significantly less postoperative acetaminophen consumption and lower dosages of perioperative sufentanyl and remifentanil compared with the CON group. The length of stay in the PACU and time to extubation were significantly increased in the CON group compared with the NE group. Time to first bowel movement and time to first flatus were earlier in the NB group. But there were no significant differences between the groups in terms of the length of hospital stay and codeine tablet consumption. CONCLUSION: Ultrasound-guided SAPB and TTMP blocks in patients undergoing the Nuss procedure could provide effective analgesia. TRIAL REGISTRATION: This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038506).

Pectus Disorders: Excavatum, Carinatum and Arcuatum.

This article reviews pectus excavatum, carinatum, and arcuatum. Topics covered include etiology, epidemiology, associated syndromes, physiologic impact, workup, indications for treatment, surgical and nonsurgical therapy, results, complications, and emerging therapies. Pectus excavatum is an inward deformation of the sternum and/or anterior chest wall. Pectus carinatum is ether an outward protrusion or tilt of the sternum with potential psychological impact, but no demonstrated physiologic impact. Nonoperative compression bracing is successful in carinatum patients with chest wall flexibility who are compliant with a bracing program. Pectus arcuatum is an abnormally short, fully fused sternum with a high anterior protrusion.

Intraventricular Thrombosis and Pulmonary Embolism Post-Nuss Procedure: A Rare Case of Chronic Bar Displacement in a 16-Year-Old Patient.

This novel report presents the first known case, to our knowledge, of a 16-year-old male patient who experienced intraventricular thrombosis and pulmonary embolism after a Nuss procedure for pectus excavatum, attributed to chronic bar displacement. Two years after the operation, the patient experienced post-exercise cough and hemoptysis, which led to his admission. Imaging revealed pulmonary embolism, thrombosis in the right ventricular outflow tract, and lung infiltrative lesions. We hypothesize that the chronic bar displacement led to its embedment in the right ventricle, resulting in thrombus formation, which subsequently contributed to partial pulmonary embolism. Surgery revealed the bars' intrusion into the right ventricle and lung. This case highlights the risk of severe complications from bar displacement in the Nuss procedure, which necessitates long-term follow-up evaluation, caution against strenuous activities after surgery, and use of thoracoscopic guidance during bar implantation and removal. It underscores the importance of vigilant evaluation for late-stage complications in patients with respiratory distress or thrombosis after a Nuss procedure.

Ultrasound-guided erector spinae plane block versus thoracic epidural block for postoperative analgesia in pediatric Nuss surgery: a randomized noninferiority trial.

PURPOSE: Thoracic epidural anesthesia (TEA) is often used for analgesia after thoracic surgery. Erector spinae plane block (ESPB) has been proposed to provide adequate analgesia. We hypothesized that ESPB would be noninferior to TEA as a part of multimodal analgesia in pediatric patients undergoing the Nuss procedure. METHODS: Patients aged 7-18 years and scheduled for the Nuss procedure were randomly allocated to receive bilateral single-shot ESPB or TEA and a multimodal analgesic regimen including parent-controlled intravenous analgesia (PCIA). At 6 h, 12 h, 18 h, and 24 h postoperatively, pain was evaluated using the numeric rating scale (NRS) and opioid consumption was assessed by counting the number of PCIA boluses. The joint primary outcomes were the average pain score and opioid consumption at 24 h after surgery. The secondary outcomes were the NRS scores and the number of opioid boluses administered at different postoperative time points, adverse events, and recovery quality. RESULTS: Three hundred patients underwent randomization, and 286 received ESPB (147 patients) or TEA (139 patients). At 24 h postoperatively, ESPB was noninferior to TEA in terms of the average NRS score (mean difference, - 0.1, 95% confidence interval [CI], - 0.3-0.1, margin = 1, P for noninferiority < 0.001) and the number of opioid boluses administered (mean difference, - 1.1, 95% CI, - 2.8-0.6, margin = 7, P for noninferiority < 0.001). Adverse events and patient recovery were comparable between groups. CONCLUSIONS: The results demonstrate that combined with a multimodal analgesia, ESPB provides noninferior analgesia compared to TEA with respect to pain score and opioid consumption among pediatric patients undergoing the Nuss procedure.

Biocompatible Cable Ties Are an Alternative to Metal Stabilizers for Bar Securement During Minimally Invasive Pectus Excavatum Repair.

Background: Bar stabilization during minimally invasive pectus excavatum repair (MIRPE) is critical to avoid dislodgement. Multiple techniques are described including stabilizers, wires, and sutures. This retrospective study compared bar movement and outcomes between existing techniques and ZipFix™, a biocompatible cable tie. Methods: Patients ≤20 years of age who underwent MIRPE with ZipFix between January 2021 and September 2022 were compared with historical controls who underwent repair by same surgeons between January 2018 and December 2020 using stabilizers or polydioxanone suture (PDS). Demographics, clinical details, and outcomes were compared using Kruskal-Wallis and chi-square tests. Results: Of the 116 patients who underwent repair, 45 had bars secured with ZipFix (39%) and 71 (61%) were historical controls (35 stabilizer, 36 PDS). Median (interquartile range) age was 15 (14-16) years and Haller index was 3.9 (3.6-4.5). Nine (8%) patients required two bars. Haller index and use of second bar were comparable between stabilization techniques (P > .05). In total, 49 patients (40%) reported any pain at 1 month and this was similar between stabilization techniques (P = .45). Median bar movement was greater for bars secured with PDS than with ZipFix or stabilizers at 1 month (5.5 versus 2.3 versus 3.3°, P = .010) and last follow-up (6.5 versus 2.1 versus 3.6°, P < .001). One patient whose bar was secured with PDS required revision for dislodgement. Conclusion: Pectus bar stabilization with ZipFix is a safe alternative to metal stabilizers and both techniques are superior to suture stabilization alone. The use of ZipFix may be preferred given its lower cost and ease of use.

Polytherapy versus monotherapy in the treatment of tibial non-unions: a retrospective study.

BACKGROUND: Treating tibial non-unions efficiently presents a challenge for orthopaedic trauma surgeons. The established gold standard involves implanting autologous bone graft with adequate fixation, but the addition of biologicals according to the so-called diamond concept has become increasingly popular in the treatment of non-unions. Previous studies have indicated that polytherapy, which involves implanting mesenchymal stem cells, bioactive factors and osteoconductive scaffolds, can improve bone healing. This study aims to evaluate the efficacy of polytherapy compared with monotherapy in treating tibial non-unions of varying severity. MATERIALS AND METHODS: Data from consecutive tibial non-unions treated between November 2014 and July 2023 were retrospectively analysed. The Non Union Scoring System (NUSS) score before non-union surgery, and the Radiographic Union Score for Tibial fractures (RUST), scored at 1, 3, 6, 9, 12 and 18 months post-surgery, were recorded. Initially, a comparison was made between the polytherapy and monotherapy groups. Subsequently, patients receiving additional surgical non-union treatment were documented, and the frequency of these treatments was tallied for a subsequent per-treatment analysis. RESULTS: A total of 34 patients were included and divided into a polytherapy group (n = 15) and a monotherapy group (n = 19). The polytherapy group demonstrated a higher NUSS score (44 (39, 52) versus 32 (29, 43), P = 0.019, z = -2.347) and a tendency towards a higher success rate (93% versus 68%, P = 0.104) compared with the monotherapy group. For the per-treatment analysis, 44 treatments were divided into the polytherapy per-treatment group (n = 20) and the monotherapy per-treatment group (n = 24). The polytherapy per-treatment group exhibited a higher NUSS score (48 (43, 60) versus 38 (30, 50), P = 0.030, z = -2.173) and a higher success rate (95% versus 58%, P = 0.006) than the monotherapy per-treatment group. Within the monotherapy per-treatment group, the NUSS score displayed excellent predictive performance (AUC = 0.9143). Setting the threshold value at 48, the sensitivity and specificity were 100.0% and 70.0%, respectively. CONCLUSIONS: Polytherapy is more effective than monotherapy for severe tibial non-unions, offering a higher success ratio. The NUSS score supports decision-making in treating tibial non-unions. LEVEL OF EVIDENCE: Level III.

Does a high Haller index influence outcomes in pectus excavatum repair?

OBJECTIVE: Severity for pectus excavatum includes Haller index (HI) > 3.25. An extremely high HI (≥8) may influence surgical approach and complications. This study reviews outcomes of patients with high HI after repair. METHODS: A single institution retrospective analysis was performed on adult patients with HI ≥ 8 undergoing pectus excavatum repairs. For outcomes, a propensity score-matched control group with a HI ≤ 4 was utilized. RESULTS: In total, 64 cases (mean age, 33.5 ± 10.9 years; HI, 13.1 ± 5.0; 56% women) were included. A minimally invasive repair was successful in 84%. A hybrid procedure was performed in the remaining either to repair fractures of the ribs (8 patients) and sternum (5 patients) or when osteotomy and/or cartilage resection was required (10 patients). In comparison with the matched cohort (HI ≤ 4), patients with high HI had longer operative times (171 vs 133 minutes; P < .001), more frequently required hybrid procedures (16% vs 2%; P = .005), experienced higher incidences of rib (22% vs 3%; P = .001) and sternal fractures (12% vs 0%; P = .003), and had increased repair with 3 bars (50% vs 19%; P < .001). There were no significant differences between the groups for length of hospital stay or postoperative 30-day complications. CONCLUSIONS: Patients with an extremely high HI can be challenging cases with greater risks of fracture and need for osteotomy/cartilage resection. Despite this, minimally invasive repair techniques can be utilized in most cases without increased complications when performed by an experienced surgeon.

Pectus excavatum. Surgical treatment: Structural or aesthetic?

INTRODUCTION: Pectus excavatum is a wall deformity that often warrants medical evaluation. In most cases, it's a purely visual aesthetic alteration, while in others, it comes with symptoms. Several surgical techniques have been described, but their outcomes are difficult to assess due to the heterogeneity of presentations and the lack of long-term follow-up. We present our experience as thoracic surgeons, assessing correction as either structural (remodeling of the thoracic cage through open surgery) or aesthetic (design and implantation of a customized 3D prosthesis). MATERIAL AND METHODS: Retrospective observational study of the indication for surgical treatment of pectus excavatum carried out by a team of thoracic surgeons and the short- to mid-term results. RESULTS: Between 2021 and 2023, we treated 36 cases surgically, either through thoracic cage remodeling techniques or with 3D prostheses. There were few minor complications, and the short- to mid-term results were positive: alleviation of symptoms or compression of structures when present, or aesthetic correction of the defect in other cases. CONCLUSIONS: Surgery for pectus excavatum should be evaluated for structural correction of the wall or aesthetics. In the former, thoracic cage remodeling requiring cartilage excision and possibly osteotomies is necessary. In the latter, the defect is corrected with a customized 3D prosthesis.

S-ICD Implantation in Secondary Prevention in a Young Patient With Recent Surgically Repaired Pectus Excavatum.

We report a case of successful implantation of a subcutaneous implantable cardioverter-defibrillator in a young patient with severe pectus excavatum presenting with out-of-hospital ventricular fibrillation arrest who was recently surgically repaired with a MIRPE-Nuss procedure. No complications in lead positioning were observed, and the device was tested to determine that it functioned properly.

Impact of delayed removal of pectus bar on outcomes following Nuss repair: a retrospective analysis.

BACKGROUND: Usually, pectus bars are removed 3 years after the Nuss procedure in patients with pectus excavatum. However, the optimal timing for postoperative pectus bar removal remains undefined. Our study investigated the effects of delayed pectus bar removal after Nuss repairs. METHODS: Retrospective data were collected on patients who underwent Nuss procedures for pectus excavatum and had their bars removed from August 2014 to December 2020. Patients with correction periods > 3 years were divided into group A (< 6 years) and group B (≥ 6 years). Propensity score matching was used to compare complications and radiological outcomes associated with bar removal. RESULTS: Of the 542 patients who underwent bar removal, 451 (Group A: 419 patients, Group B: 32) had correction duration > 3 years. The average correction duration was 4.5 ± 1.4 years. After propensity score matching analysis, group B [median duration: 8.0 (6.0-16.2) years] exhibited significantly longer median operative times (85 vs. 55 min; P = 0.026), higher callus formation rates (68.8% vs. 46.9%; P = 0.029), and greater median intraoperative blood loss (35 vs. 10 mL; P = 0.017) than group A [median duration: 4.2 (3.0-5.9) years]. However, following bar removal, the groups showed no statistical differences in the surgical complication rates (group A: 6.3% vs. group B: 9.4%; P = 0.648) or median ratio of radiological improvement (an improvement on the Haller index on chest radiography; 21.0% vs. 22.2%; P = 0.308). CONCLUSIONS: Delaying pectus bar removal after Nuss repair presents certain challenges but does not compromise overall outcomes. These findings suggest that a longer correction period may be unnecessary. However, further multicenter studies with long-term follow-up are warranted to assess long-term outcomes.