The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Appraise and evaluate risk factors for respiratory compromise following oncologic resection. 2. Outline and apply an algorithmic approach to reconstruction of the chest wall based on defect composition, size, and characteristics of surrounding tissue. 3. Recognize and evaluate indications for and types of skeletal stabilization of the chest wall. 4. Critically consider, compare, and select pedicled and free flaps for chest wall reconstruction that do not impair residual respiratory function or skeletal stability. SUMMARY: Chest wall reconstruction restores respiratory function, provides protection for underlying viscera, and supports the shoulder girdle. Common indications for chest wall reconstruction include neoplasms, trauma, infectious processes, and congenital defects. Loss of chest wall integrity can result in respiratory and cardiac compromise and upper extremity instability. Advances in reconstructive techniques have expanded the resectability of large complex oncologic tumors by safely and reliably restoring chest wall integrity in an immediate fashion with minimal or no secondary deficits. The purpose of this article is to provide the reader with current evidenced-based knowledge to optimize care of patients requiring chest wall reconstruction. This article discusses the evaluation and management of oncologic chest wall defects, reviews controversial considerations in chest wall reconstruction, and provides an algorithm for the reconstruction of complex chest wall defects. Respiratory preservation, semirigid stabilization, and longevity are key when reconstructing chest wall defects.

Effect of physical therapy intervention on thickness and ratio of the sternocleidomastoid muscle and head rotation angle in infants with congenital muscular torticollis: A randomized clinical trial (CONSORT).

BACKGROUND: Early diagnosis as well as treatment is important in management of congenital muscular torticollis (CMT). The purpose of this study was to find an effective physical therapy modality to improve the sternocleidomastoid (SCM) muscle thickness, the ratio of the SCM muscle thickness on the affected side to that on the non-affected side (A/N ratio), and head rotation in infant under 3 months of age diagnosed with CMT. METHODS AND ANALYSIS: A single-blind, randomized clinical trial was conducted. Participants were assigned in one of the 3 study groups through randomization. The treatment was performed 3 times a week for 30 minutes until the head tilt was ≤5 degrees. Group 1 was treated by handling for active or active-assist movement, group 2 was treated with passive stretching, and group 3 was treated with thermotherapy. For general characteristics, a χ2 test and 1-way analysis of variance were used. Intragroup differences were analyzed using a paired t test, and intergroup differences were analyzed using an age-adjusted analysis of covariance. RESULTS: After the intervention, there was no significant difference between groups in terms of SCM thickness on the affected side and A/N ratio (P > .05). Degree of head rotation on the affected side showed significant differences between groups (P < .05), with Group 2 showing significantly better results than group 1 and group 3 (P < .05, both). CONCLUSION: Passive stretching treatment was more effective than other treatments of this study for improvement in degree of head rotation in CMT infants under 3 months of age. TRIAL REGISTRATION: The trial is registered at the Institutional Review Board of Sahmyook University (IRB number, 2-7001793-AB-N-012019103HR) and the Clinical Research Information Service (CRiS; registry number, KCT0004862).

Comparison of bone wax and chitosan usage on post-sternotomy bone healing.

BACKGROUND: Sternotomy is a standard approach performed in almost every surgical procedure on the heart and mediastinum. Effective hemostasis of the sternum is required to keep the operative field dry, avoid excessive blood transfusions during surgery, and prevent reoperation due to massive postoperative bleeding, which can further increase morbidity and mortality in patients. Bone wax is a mechanical hemostat commonly used after sternotomy and has been known to affect bone healing, trigger chronic inflammatory reactions, and increase the rate of infection. The application of chitosan, which has intrinsic hemostat ability, as hemostatic material is believed to improve bone healing following sternotomy. This study aimed to compare the effectiveness of bone wax and chitosan on bone healing after sternotomy. METHODS: Median sternotomies were performed on 2 groups of New Zealand White rabbits. Each group of 16 animals received either bone wax or chitosan powder as hemostatic material. The degree of bone healing, the number of foreign-body giant cells, and the number of osteoblasts were evaluated after 6 weeks. RESULTS: Radiographs showed that significantly more animals in the chitosan group had total sternal healing (p = 0.033). Histopathology revealed that the number of foreign-body giant cells was significantly less (p = 0.036) and the number of osteoblasts was significantly greater (p < 0.0001) in the group of animals that received chitosan. CONCLUSION: The use of chitosan as hemostatic material can promote better bone healing compared to bone wax.

Development of chest deflection injury risk curve in oblique frontal small female PMHS sled tests.

OBJECTIVE: The study's aim is to examine which sternum deflection measure best represents injury in oblique frontal impacts with small female surrogates. METHODS: Data from sixteen PMHS sled tests were used to calculate sternum deflection using displacements in the A-P (x) direction, transverse (xy) plane, sagittal (xz) plane, and triplanar (xyz). Peak deflections were the response variable and were combined with injury outcomes to generate injury risk curves (IRCs) using parametric statistical survival modeling. The IRC with the lowest Brier Score Metric was considered the best deflection measure representing injury. RESULTS: The triplanar (xyz) deflection metric was the best indicator of injury. At the 10 and 50% probability levels, the magnitudes of this metric were 33 mm and 55 mm, respectively. The quality of the risk curve was fair for 10% and good for 50%, based on the ISO recommendations. CONCLUSIONS: The current study reports on the injury risk to small females in an upright seated position in oblique frontal impacts. The triplanar and transverse plane deflection metrics were similar for this posture; however, occupants in reclined configurations may demonstrate a different response, and further investigations are necessary.

Effectiveness of Compressive External Bracing in Patients with Flexible Pectus Carinatum Deformity: A Review.

There has been a growing interest in the nonoperative treatment of chest wall deformities over the last few decades; with the advent of external compressive orthotics, similar outcomes have been reported compared with surgical intervention. There have been fewer major complications reported with dynamic compression bracing on the chest wall; however, the Achilles heel of this approach still lies with treatment tolerability and compliance. A Medline literature search was undertaken to evaluate the evidence concerning the techniques, modifications, and outcomes associated with external compressive bracing in the setting of pectus carinatum. Sixteen articles were integrated after literature review and data were collected on methods of assessing pectus carinatum (degree of severity as well as type), patient selection protocol (i.e., suitability for external compressive bracing), the bracing protocol itself, duration of treatment, metrics used to assess outcome, and success, compliance, and dropout rate, and length of long-term follow-up. Compressive external bracing appears to be a safe and well tolerated nonsurgical treatment option for young patients with flexible pectus carinatum deformities. However, there is still a need for robust level I randomized data from multiple centers with a clearly standardized bracing protocol, objective measurement of outcomes, and recording of results at the end of the bracing treatment program in sufficiently powered sample sizes over a significant follow-up period.

The peculiarities and treatment outcomes of the spinal form of chronic non-bacterial osteomyelitis in children: a retrospective cohort study.

Chronic non-bacterial osteomyelitis (CNO) is a group of immune-mediated diseases which appears in bone inflammation, destruction and some orthopaedic consequences, especially in the cases of spinal involvement. This study is to compare characteristics and treatment outcomes of CNO patients with spinal involvement. The retrospective cohort study included data from 91 pediatric patients with CNO. The diagnosis is based on Jannson's criteria with morphological confirmation (nonspecific chronic inflammation). Spine involvement detected by X-ray, computed tomography, magnetic resonance imaging, and bone scan in 29 (31.9%) patients. No differences in the family history, concomitant immune-mediated diseases between spinal (SpCNO) and peripheral (pCNO) forms of CNO have been revealed. Only 5 (10.2%) SpCNO patients (10.2%) had monofocal monovertebral involvement. The main risk factors of spinal involvement were female sex: RR = 2.0 (1.1; 3.9), sensitivity (Se) = 0.66, specificity (Sp) = 0.6; multifocal involvement: RR = 2.1 (0.9; 5.0), Se = 0.83, Sp = 0.37; no foot bones involvement: RR = 3.1 (1.3; 7.5), Se = 0.83, Sp = 0.5; sternum involvement RR = 2.3 (1.3; 4.1), Se = 0.24, Sp = 0.94. In the linear regression analysis only female sex (p = 0.005), multifocal involvement (p = 0.000001) and absence of foot bones involvement (p = 0.000001) were independent risk factors of spinal involvement (p = 0.000001). The response rate on bisphosphonates and tumor necrosis factor-a inhibitors was 90.9% and 66.7%, consequently. Only 4/29 (13.8%) SpCNO patients underwent surgery due to severe spinal instability or deformities. The spinal involvement is frequent in CNO and could be crucial for choosing a treatment strategy. Bisphosphonates and TNFa-inhibitors could be effective treatment options for severe SpCNO.

Improved Healing by Adjuvant Osteoconductive Therapy Using a Novel Cotton-Like Hydroxyapatite Sheet After Median Sternotomy.

The union rate of wire fixation after median sternotomy remains unsatisfactory. We developed a novel osteoconductive sheet composed of hydrophilized hydroxyapatite and evaluated its osteogenetic effect when interposed between sternal halves in a canine model. Eighteen canines were divided equally into groups based on the hemostatic agent used: osteoconductive sheet (S), none (C), and bone wax (BW). After median sternotomy, the sternal halves were closed by wire fixation. In each group, 3 canines were euthanized at 1 month, while 3 were euthanized at 2 months. Resected sternums were mechanically assessed by the 3-point bending test, radiographically assessed by micro-CT, and pathologically assessed to quantify the osteogenesis between sternal halves. Compared with the BW group, the S group had a greater maximum stress at 1 month (S: 322.9 ± 107.7 N, C: 233.0 ± 62.7 N, BW: 124.9 ± 88.4 N; P = 0.025), and greater maximum shear force at 1 month (S: 1.92 ± 0.67 N/m2; C: 1.23 ± 0.28 N/m2; BW: 0.68 ± 0.41 N/m2; P = 0.025). Micro-CT revealed that the S group had more osteogenesis than the BW group at 1 month (25.7% ± 9.8% vs 6.9% ± 9.2%), and 2 months (34.0% ± 15.1% vs 14.8% ± 9.4%); the respective values in the C group were 17.1% ± 7.2% and 29.7% ± 9.3%. Pathologic examination revealed that the S group had the greatest osteogenetic area at 2 months (S: 38.8% ± 18.8%; C: 24.5% ± 6.9%; BW: 24.7% ± 18.6%). Adjuvant osteoconductive therapy using a cotton-like hydroxyapatite sheet in addition to wire fixation significantly improved sternal healing compared with BW. This new material also showed relatively better outcome than the C group.

Motion at the Sternal Edges During Upper Limb and Trunk Tasks In-Vivo as Measured by Real-Time Ultrasound Following Cardiac Surgery: A Three-Month Prospective, Observational Study.

BACKGROUND: Despite a paucity of evidence, patients following cardiac surgery via median sternotomy are routinely prescribed sternal precautions that restrict upper limb and trunk movements, with the rationale of reducing postoperative sternal complications such as sternal wound dehiscence, instability, infection and/or pain. The primary aim of this study was to measure motion at the sternal edges during dynamic upper limb and trunk tasks to better inform future sternal precautions and optimise postoperative recovery. Motion at the sternal edges was measured using ultrasound, which has been demonstrated to be a clinically valid and reliable measure in patients following cardiac surgery. METHODS: Seventy-five (75) patients following cardiac surgery via median sternotomy with conventional stainless steel wire closure were recruited. Motion at the sternal edges in the lateral (coronal plane) and anterior-posterior (sagittal plane) directions was measured at the level of the fourth intercostal space (mid-sternum) using ultrasound. Ultrasound measures were taken at rest and during five dynamic upper limb and trunk tasks (deep inspiration, cough, unilateral and bilateral upper limb elevation and sit to stand), over the first 3 postoperative months (3 to 7 days, 6 weeks and 3 months postoperatively). Sternal pain, functional status and sternal healing were also observed over the same postoperative period. RESULTS: The magnitude of overlap of the sternal edges in the lateral direction, and separation of the sternal edges in the anterior-posterior direction, both significantly decreased by 0.01cm, over the first 3 postoperative months (p<0.01). Coughing, however, produced a significant increase in separation of the sternal edges in the lateral direction (0.01-0.02cm) and pain (12-63%), compared to rest and all other tasks, at each postoperative time point (p<0.01). Additionally, there was a significant decrease in sternal pain (81%) and increase in postoperative function (79%) over the same postoperative period (p<0.01). At 3 months postoperatively, five (7%) participants demonstrated radiological sternal union and one (1%) participant was diagnosed with clinical sternal instability. CONCLUSIONS: A small magnitude of multi-planar motion at the sternal edges, at the mid-sternum, was demonstrated during dynamic upper limb and trunk tasks in a cohort of cardiac surgery patients post-sternotomy, over the first 3 postoperative months. Future research investigating motion at different levels of the sternum, with varying methods of sternal closure, and over a longer postoperative period is warranted to better inform sternal precautions and optimise postoperative recovery.

[Surgical treatment of pectus carinatum in children]. / Khirurgicheskoe lechenie kilevidnoi deformatsii grudnoi kletki u detei.

AIM: To improve the results of surgical treatment of pectus carinatum. MATERIAL AND METHODS: The work included 47 pectus carinatum patients aged 3-15 years for the period from 2000 to 2015. All patients were divided into 2 groups depending on surgical approach: control group - 23 (48.94%) children who underwent thoracoplasty by M.M. Ravitsh procedure with the use of device for pectus carinatum repair of our design; main group - 24 (51.06%) patients where our method of thoracoplasty based on changes of deformed ribs biomechanics was used. RESULTS: In control group good results were obtained in 15 (65.3%) patients, satisfactory - in 5 (21.7%) patients, recurrent deformation with all consequences was observed in 3 (13%) cases. Long-term results of surgical treatment by original method were followed-up in all 24 patients and good outcomes were obtained in 100% of children. CONCLUSION: 1) Intraoperative 'spring' - effect is a provoking risk factor of recurrent chest deformation. 2) The new surgical method based on breaking the ribs bodies in 'green branch' fashion provides good results and does not require external devices to hold sternal-rib complex in corrected position.

Early Surgical Reconstruction of Sternum with Longitudinal Rigid Polymer Plating after Acute Chest Trauma.

PURPOSE: The surgical management of the patients with traumatic sternal fractures remains controversial. The aim of this study was to evaluate the effectiveness of an early surgical reconstruction of a displaced sternal fracture utilizing longitudinal rigid polymer fixation in the settings of an acute chest trauma. METHODS: To perform the sternal fixation, we utilized a longitudinal rigid plating system. The plate is made of polyether ether ketone (PEEK), an organic thermoplastic polymer. RESULTS: We used the entire length of the plate on each side of the fracture, secured in multiple places with 6-8 screws. Once the plates have been fully secured we tighten all the screws with a screwdriver. We demonstrated that the method minimizes pain and prevents the development of pulmonary complications. CONCLUSION: This technique provides cosmetically acceptable results, minimizing risk of sternal nonunion, and decreases length of hospitalization.

Solitary Osteogenic Sternum Plasmacytoma on Bone Scintigraphy and FDG PET/CT.

We reported a rare solitary osteogenic sternum plasmacytoma case. A 49-year-old woman experienced progressing pain in the sternum for 2 years. Abnormal Tc-MDP accumulation and increase in F-FDG uptake (SUVmax, 4.4) were co-localized with the osteogenic lesion in the sternum body detected by diagnostic CT. The lesion was histologically confirmed as plasma cell neoplasm suggestive of plasmacytoma. The patient had good response to radiotherapy.

A biomechanical study of 4 different sternum closure techniques under different deformation modes.

OBJECTIVES: This study experimentally compares the efficiency of the 4 most preferred sternal closure tehniques, in 3 different deformation modes of the chest. METHODS: Polyurethane sternum models fixed by conventional wiring, steel band, ZipFix band and figure-8 wiring are tested statically under lateral distraction, longitudinal shear and torsional deformation modes. As a result, load-deformation curves are obtained. The closure efficiency of the techniques is then compared with respect to allowable load (corresponding to 2 mm displacement), rigidity, rupture load and rupture displacement. A comparison in terms of cost and ease of application has also been presented. RESULTS: The highest allowable load and rigidity values in simple tension and longitudinal shear are obtained by the steel and ZipFix band techniques, respectively. In torsion mode, the highest allowable load is provided by the ZipFix band and the highest rigidty is attained by the steel band technique. The highest rupture loads under simple tension, longitudinal shear and torsion modes are observed in ZipFix, steel band and conventional wiring, respectively. Steel band closure provides the least rupture displacement in simple tension as well as torsion, whereas ZipFix bands give the smallest rupture displacements in longitudinal shear. However, in every loading mode there were no statistically significant differences in allowable load, rigidity and rupture load values between the closure methods, and only rupture displacement values were statistically different for each method. CONCLUSIONS: Our results showed that conventional wiring is the most advantageous closing method when compared to the others.

Small female rib cage fracture in frontal sled tests.

OBJECTIVES: The 2 objectives of this study are to (1) examine the rib and sternal fractures sustained by small stature elderly females in simulated frontal crashes and (2) determine how the findings are characterized by prior knowledge and field data. METHODS: A test series was conducted to evaluate the response of 5 elderly (average age 76 years) female postmortem human subjects (PMHS), similar in mass and size to a 5th percentile female, in 30 km/h frontal sled tests. The subjects were restrained on a rigid planar seat by bilateral rigid knee bolsters, pelvic blocks, and a custom force-limited 3-point shoulder and lap belt. Posttest subject injury assessment included identifying rib cage fractures by means of a radiologist read of a posttest computed tomography (CT) and an autopsy. The data from a motion capture camera system were processed to provide chest deflection, defined as the movement of the sternum relative to the spine at the level of T8. A complementary field data investigation involved querying the NASS-CDS database over the years 1997-2012. The targeted cases involved belted front seat small female passenger vehicle occupants over 40 years old who were injured in 25 to 35 km/h delta-V frontal crashes (11 to 1 o'clock). RESULTS: Peak upper shoulder belt tension averaged 1,970 N (SD = 140 N) in the sled tests. For all subjects, the peak x-axis deflection was recorded at the sternum with an average of -44.5 mm or 25% of chest depth. The thoracic injury severity based on the number and distribution of rib fractures yielded 4 subjects coded as Abbreviated Injury Scale (AIS) 3 (serious) and one as AIS 5 (critical). The NASS-CDS field data investigation of small females identified 205 occupants who met the search criteria. Rib fractures were reported for 2.7% of the female occupants. CONCLUSIONS: The small elderly test subjects sustained a higher number of rib cage fractures than expected in what was intended to be a minimally injurious frontal crash test condition. Neither field studies nor prior laboratory frontal sled tests conducted with 50th percentile male PMHS predicted the injury severity observed. Although this was a limited study, the results justify further exploration of the risk of rib cage injury for small elderly female occupants.

A biomechanical study of relationship between sternum defect patterns and thoracic respiration.

BACKGROUND: Various types of sternum defects are produced after the removal of thoracic tumors involving the sternum. The present study aims to elucidate the relationship between the defect patterns and their effects on thoracic respiration. METHODS: Ten sets of finite element models were produced simulating thoraces of 10 persons and termed normal models. With each of the 10 normal models, the sternum was removed in six different ways to produce new models termed defect models. Defect models were categorized into hemi-superior (H-S), hemi-inferior (H-I), hemi-whole length (H-W), bilateral-superior (B-S), bilateral-inferior (B-I), and bilateral-whole length (B-W) defect types, depending on the locations of the defects. Respiratory movement was dynamically simulated with these models. The volume change the thoraces present during respiration was measured to evaluate the effectiveness of thoracic respiration. This value - defined as ΔV - was calculated and was compared between normal and defect models. RESULTS: With H-W and B-W type models, ΔV dropped to around 20% of normal values. With H-S and B-S type models, ΔV dropped to around 50% of normal values. With H-I and B-I type models, ΔV presented values almost equivalent to those of normal models. CONCLUSION: Effectiveness of thoracic respiration is seriously impaired when the whole length of the sternum is absent. Reconstruction of the defect is essential for these cases. However, since the upper part of the sternum is most important for effective thoracic respiration, priority should be placed on the upper part in performing reconstruction.

Scoring of Deformed Costal Cartilages Reduces Postoperative Pain after Nuss Procedure for Pectus Excavatum.

OBJECTIVE: The present study aims to elucidate whether or not scoring deformed cartilages reduces postoperative pain after the Nuss procedure for pectus excavatum patients. METHODS: A total of 46 pectus excavatum patients for whom the Nuss procedure was conducted were included in the study. The patients were categorized into two groups, depending on whether or not the supplementary maneuver of scoring deformed cartilages was performed in addition to the Nuss procedure. Patients for whom deformed costal cartilages were scored were categorized as the Scoring Group (n = 24); those who received no such scoring were categorized as the Non-Scoring Group (n = 22). After evaluating the maximum stresses occurring on the thoraces by means of dynamic simulation using finite element analyses, intergroup comparison of the maximum von-Mises stress values was performed. Furthermore, after quantifying postoperative pain as the frequency with which patients injected anesthetics through an epidural pain-control system within 2 postoperative days, the degree of pain was compared between the two groups. RESULTS: The maximum stresses occurring on the thorax were significantly greater for the Non-Scoring Group than for the Scoring Group; injection frequency was also greater for the Non-Scoring Group (average 4.9 times for 2 days) than for the Scoring Group (average 2.5 times for 2 days). CONCLUSION: High stresses occur due to the performance of the Nuss procedure, causing postoperative pain. The stresses can be reduced by performing supplementary scoring on deformed cartilages. Accordingly, postoperative pain is reduced.

Class II pentalogy of Cantrell.

BACKGROUND: Pentalogy of Cantrell is a rare syndrome, first described by Cantrell and co-workers in 1958. The syndrome is characterized by the presence of five major congenital defects involving the diaphragm, abdominal wall, the diaphragmatic pericardium, lower sternum and various congenital intra-cardiac abnormalities. The syndrome has never been reported in Tanzania, although may have been reported from other African countries. Survival rate of the complete form of pentalogy of Cantrell is as low as 20%, but recent studies have reported normal growth achieved by 6 years of age where corrective surgeries were done; showing that surgical repair early in life is essential for survival. CASE PRESENTATION: The African baby residing in Tanzania was referred from a district hospital on the second day of life. She was noted to have a huge omphalocele and ectopia cordis covered by a thin membrane, with bowels visible through the membrane and the cardiac impulse visible just below the epigastrium. Despite the physical anomaly, she appeared to saturate well in room air and had stable vitals. Her chest X-ray revealed the absence of the lower segments of the sternum and echocardiography showed multiple intra-cardiac defects. Based on these findings, the diagnosis of pentalogy of Cantrell was reached. On her fifth day of life, the neonate was noted to have signs of cardiac failure characterized by easy fatigability and restlessness during feeding. Cardiac failure treatment was initiated and she was discharged on parents' request on the second week of life. Due to inadequate facilities to undertake this complex corrective surgery, arrangements were being made to refer her abroad. In the meantime, her growth and development was satisfactory until the age of 9 months, when she ran out of the medications and succumbed to death. Her parents could no longer afford transport cost to attend the monthly clinic visits, where the infant was getting free medication refill. CONCLUSIONS: The case reported here highlights that in resource limited settings; poor outcome in infants with complex congenital anomalies is a function of multiple factors. However, we believe that surgery would have averted mortality in this 9-month-old female infant. We hope to be able to manage these cases better in future following the recent establishment of cardiac surgery facilities at Muhimbili National Hospital.

The association between changes in pressure pain sensitivity and changes in cardiovascular physiological factors associated with persistent stress.

OBJECTIVES: To evaluate the possible association between pressure pain sensitivity of the chest bone (PPS) and cardiovascular physiological factors related to persistent stress in connection with a three-month PPS-guided stress-reducing experimental intervention programme. METHODS: Forty-two office workers with an elevated PPS (≥ 60 arbitrary units) as a sign of increased level of persistent stress, completed a single-blinded cluster randomized controlled trial. The active treatment was a PPS (self-measurement)-guided stress management programme. Primary endpoints: Blood pressure (BP), heart rate (HR) and work of the heart measured as Pressure-Rate-Product (PRP); Secondary endpoints: Other features of the metabolic syndrome. RESULTS: PPS decreased and changes in PPS after the intervention period were significantly associated with HR, PRP, body mass index (BMI) and visceral fat index (all correlation coefficients > 0.2, p < 0.05). Compared to the control cluster group, the active cluster group obtained a significant reduction in PPS, Low-density lipoprotein (LDL) cholesterol and total number of elevated risk factors (p < 0.05). On an individual level, significant and clinically relevant between-group reductions were observed in respect to BP, HR, PRP, total and LDL cholesterol, and total number of elevated risk factors (p < 0.05). CONCLUSIONS: The stress intervention method applied in this study induced a decrease in PPS which was associated with a clinically relevant decrease in resting blood pressure, heart rate, work of the heart and serum cholesterols.

Nuss procedure in adult pectus excavatum: a simple artifice to reduce sternal tension.

Nowadays the Nuss operation represents the standard surgical choice for pectus excavatum repair in children and teenagers. Some concerns have been raised regarding its applicability in adults, as compared with younger patients, in view of the higher rate of complications after surgery. We describe an easy trick that has been performed on a 36-year old man with a moderate pectus excavatum after an unsatisfactory Nuss procedure. It consisted of a T-shaped partial anterior sternotomy, performed after positioning of the stainless steel bar, in order to promote a hinge mechanism of the sternum to reduce the tension over the reinforcement. This procedure was successful with well-controlled postoperative pain and great patient satisfaction. No complications were recorded at 1-year follow-up. In our opinion, this simple trick could represent a valid surgical option for pectus excavatum repair in late adolescents and adults to obviate the occurrence of major sternal tension.